HomeMy Public PortalAbout4907 RYLAND AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to Self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT LJ
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab- C.) 76A20B
CE876(3/84)
Policy Nor' -',M1 MCompany '� 71i; ,�":' ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is her furnished.
BUILDING
Certified copy is filed with the county,building inspec- FOR APPLICANT TO FILL IN ADDRESS
tion department. BUILDING
LOCALITY
ADDRESS �F `.J' /�/ ' �� +-+
Date - Applicant r1 �; ...-- _
CITY `•'f �J/"^F``, ZIP ' �` l NEARESCROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL.
t - NOS r USE ZONE MAP
hundred dollars ($100)or less.) OWNER wi Y 1,�,'�-` "' � NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS
so as to become subject to the Workers'Compensation Laws, DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST.
Date Applicant ARCHITECT OR f TEL CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' r ,-�j .. Jl /•• VALUATION
ADDRESS f ems :::!c l •�E�� }-
Compensation provisions of the Labor Code, you must forth '' VALIDATION
with comply with such provisions or this permit shall be TEL. $
deemed revoked. CONTRACTOR '�.`..' ! ,/'^1� NO. ! - - -
LICENSED CONTRACTORS DECLARATION LIC,,
ADDRESS fr is ,:•., NO-p''
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000) of Division 3 of the Business LIC.
CITY .",.: CLASS
and Professions Code, and my license is in full force and effect. "'
DESCRIPTION OF WORK
License Number
o� Lic. Class SWIMMING POOL
.� FINAL 0-
DATE
DATE o
SPA 0
Contractor. Date FINAL 7 W
Ld
SQ. FT.
I am exempt under Sec. SIZE 9Y LL_
B.BP.C. for this reason ELECTRICAL Df
Date:
Steel 8 Conduit Bonding O
Signature Conduits, Conductors, Equipment 0-
SINGLE FAMILY 2i
HOME OWNER-BUILDER DECLARATION PLUMBING Ld
I hereby affirm that I am exempt from the Contractor's License , ~
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code) Gas System
❑ I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. 1, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater 0
CONSTRUCTION LENDING AGENCY y
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT) NO, x
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS
Lender's Address J�
P.C. Fee$ permit Fee
I certify that I have read this application and state that the
above information is correct. I agree 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
mentioned property for inspection purposes.
Signature of.Apphcant or Agee+ Date SEE REVERSE FOR EXPLANATORY LANGUAGE