HomeMy Public PortalAbout4935 RYLAND AVE_Swimming Pool__ Fln� or
VIDR'KERS!COMP NSATION DECLARATION r j
'ffir'rh Waifh.Ve a'ibrtificate.of cons ant'to,seff -�'` APPLICATIO,N! FOR OMBINATION SWIMMING POOL PERMIT
cerfifica of Workers'Compensation Insurance;'... crgv.eFereof(Sec. 3800,.Lab.''C,) ' 76A20BCE,75(11/81).221
WIA1 ompan.y O: COUNTYOF LOS ANGELES' �i BUILDING AND SAFETY
d copy is hereby furnished. BUILDING"- 'wilding inspec- I FOR APPLICANT TO FILL IN ADDRESS 9 3d copy is filed4ifth the cow BUIL
1 tion departmenDINGt ADDRESS 36 LOCALITY j
' Date —�,4 ant C �'G`• ZIP �176C) • NEAREST
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE F ASSESSOR
' COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
'1 ,(Thisa etion need not be completed if the permit is For oneI 2 TEL. USE ZONE OP
I• puirdred dollars($100)or less.) O4 NER .8 NO.
rcertify that in the performance of the work for which this L A.
SPECIAL
ermit is issued, I shall not employ any person in any manner ADDRESS, S. ./'l. CONDITIONS
o'as to become subject to the Workers'Compensation Laws. { DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP i rxf CLASS NO. CONST. _
ate Applicant At CHITECT OR TEL. Y O CJ /
OTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. �„ CC!!
xemption, you should become subject to the Workers' ADDRESS
-VALUATION
UATION
ompensation provisions of the Labor Code, you.must forth- i VALIDATION
ith comply with such provisions or this permit shall be _1 /1,t / �F f,�jeZj/_ N .265 MI • •-• $
eemed revoked. NTRACiO.R "`�-'7 NO.I�.T
LICENSED CONTRACTORS DECLARATION S ' C' 23
A.,DRESS O. ACC
hereby affirm that I am Iicensed under provisions of Chapter 9 LIC. /� $ 1744TaJL
oinmencing with.Section 7000)of Division 3 of the Business CI� CLASS C�5 L
d Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK FINAL ' 176a
FINAL /1_ j .. i . 1 IT,",
cense Num09
ber 02 Lic. ClassC� SWIMMING POOL �. DATE /'!/, I/ ► 11GIh7
S�'a,11 d a ,' :; TOTAL 1?4®.2
ntractorzrf Date �,'.PA +n FINAL ��rr/�
� a BY CKCK 176a
f I am exempt under Sec. SIZES 2� $
o
OV
B.&P.C.'for this reason ELECTRICAL ��7iy_nnn,
Date:
Steel 8 Conduit Bonding � ,' ��•
Signature Conduits, Conductors, Equipment
SINGLE FAMILY ' ` 1 AH111106
HOMEOWNER-BUILDER DECLARATION PLUMBING -3
I herebyaffirm that I am exempt from the Contractor's License
j Law fothe following reason(Section 7031.5,. Business and P-Trap , ` ACCT.=
Professions Code): Gas System ; y� I .'t ' 7
M.75
I, as owner of the property, will do the plumbing and Anti-Syphon L_
electrical work. I,or my employees with wages as their l 1 ITS
sole compensation,or a licensed contractor Will do all ECHANICA.L.
other work and the structure is not intended or offered i ,TOTAL 311316-.75
i
for sale (Section 7044 B&P Code). Swimming Pool Heater M6a75
'
' CONSTRUCTION LENDING AGENCYCWM
I hereby affirm that there is a construction lending agency for APLICANT TEL ` I a00
the performance of the work for which this permit is issued (PRINT), p��jC' NO. l
� (Sec. 3097, Civ. C.). - -
0.,l f'S MIW'S 94— '%774 l - 1 5/24/89
� Lender's Name ADDRESS' ; �
3M7 1 Fp1111-06
Lender's Address f
• /e � Permit Fee
I certify that I have read this application and state that the P.C.Fee$
above information is correct. I agree to comply with all County Issuance Fee 0 1
ordinances and State laws relating to building, electrical,
mechanical and plumbing construction,and hereby out Investigation Fee 7
representatives of this County to enter upon the above- ', Total Fee '/ .J
mentioned prop f inspection purposes.
' ... i
ature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE