HomeMy Public PortalAbout6221 ROWLAND AVE_Swimming Pool__ i
WORKERS'COMPENSATION DECLARATIt N 1
here or
certificate
that I have r certificate nof satio Int to self APPLICATION FOR COMBINAVOk SWIMMING POOL PERMIT
ijsdtlre, or a certificate of Workers'Compensation Insurance,
or a�er�tif'ed opy thereo (Sec. 3800, Lab. C.) I76A20B
yt,/ Q$� � CE-875(11/81)
Policyy�o. o.mpany r" *' COUNTY OF,.LOS_ANGELES EUILDING AND SAFETY
Q Certified copy is hereby furnished. i t
� FOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county building inspec- I ADDRESS
tto department. BUILDING ee A C -G
' ADDRESS 1 tzOPA� 4AI A•. LOCALITY
Date • Applican T • NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY.{ �L ZIP .� `��® CROSS,ST.
COMPENSATION INSURANCE• SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP;BOOK I PAGE s PARCEL
(This section need not'be completed IF the permit is for orie /� '/ TEL.. USE ZONE MAP
hundred dollars($100)or less.) OWNER R s K vm� NO. 2 NO. %�eT
I certify-that in the performance of the work for which thist SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS . �p♦ . �: CONDITIONS
so as to-become subject tolthe Workers'Compensation Laws. { DISTRICT STATISTICAL CLASS' TYPE PROCESSED BY
!I CITY ZIP CLASS NO. CONST.
Date Applicant' ARCHITECT OR TEL. %
• ",NOTICE'TO APPLICANT: If, after making this Certificate of ENGINEER ( NO. i
'Ezempt bn, you should become,.subject to the Workers' i VALUATION
Compensation provisions of the Labor Code, you.must forth- • ' ADDRESS
/ �j �7y ®O VALIDATION
w'ith.'comply with such provisions or this permit shall be CONTRACTOR�'! NO. �����rlA► $ v�fV
>: deemed revoked;
LICENSED CONTRACTORS DECLARATION � ® 0 7r � LIC. Ja 1
R. ADD.RE$5 �!./P7a (II NO. d
-1 liereby,affirm that I am•licensed under provisions of Chapter 9 I LIC. $'
(com.mencing with Section 7000)of Division 3 of the Business
a4Professions Code,and my license is in full force and effect. I CITY'j CLASS � )
S-3 DESCRIPTION OF WORK ❑
rL
veense Number ,�dOZ Lic. ClassG� SWIMMING POOL �. FINAL /
p� DATE t7r�! Im
Contactor 1 ®��!_Date SPA ' �® FINAL /
t'... SQ..ZFT.`
Irpm exempt under Sec. SIZE �� h
id
B.&'C. for4his reason I .ELECTRICAL z
Date:
.•.�� ', k Steel 8 Conduit Bonding '
Signature �+ i Conduits, Conductors, Equipment
'SINGLE FAMILY �
:•�+, HOME-..OWNER-BUILDER DECLARATION 1 PLUMBING' __,2 9 012 A
I Hereby+affirm thaf,l am exxempt from the Contractor's License `
Law for the following'reason (Section 7031.5, Business and ® 1
p-Trap 0 0 o'0 o a a 0 2 2 3 .
Professions•CodGas e): + , N®
Syphon
I,'as owner of the prope?ty, will do the plumbing and j Anti-Syphon e c i 0 j(. n
electrical,work. I,or my employees with wages as their ' 0'7.2 3—'8 G�
sole compensatiori,or a licensed contractor will do all MECHANICAL
other work and the structure isnot intended or offered j , / Q `2 () 0.3 A
for sale (Section 7044 B&P Code). Swimming Pool Heater �O 0 1 U '
CONSTRUCTION-LENDING AGENCY T �7`Tem (� -.0c t o-0 o 0 3
I hereby affirm that there is a constructionMending agency for APPLICANT n " 6 2 Q 1,7 b
the performance of the work for which this permit is issued (PRINT) Np• L.� Z-,,r9.cf , i
(Sec:3097, cis. C.). ,�`f c 0 20 1.76 X
Lender's Name `�h Y F7 �' I ADDRESS
23-84
Lender's Address
P.C.Fee$ Permit Fee -
I certify that I have read this application•and state that the j
above information is correct. Iagree to comply with all County
ordinances and State laws relating'to building, electrical, Issuance Fee
mechanical and plumbing construction,and hereby authorize Investigation Fee -
representatives•of this County to .enter upon. the above- Total Fee'; I
mentioned propelty for inspection purpo s.
Signature of Applicant or Agent ate SEE REVERSE FOR EXPLANATORY'LANGUAGE