HomeMy Public PortalAbout5025 RYLAND AVE_Swimming Pool__ R5•COMF�NSATION DECLARATION p�p�p 1
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11 tri that I hov r certificate of consent to self APP Ir�a'p TI N R ®�BINA 1 N SWIMMING POOL PERMIT
tifi ate of Wprkers'Compensation Insurance, L \.(r"t1 ®mT! FOR COR711 ® J � 00
ere��f.(Sec. 38;0, Lab. C.) 20B
�'ompany COUNT4 OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
BUILDING
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS L-
tion departmen_y BUILDING 5D -��
a DRESS JlJ ,,JJ y, LOCALITY
Dda CERTIFICATE OF EXEM Applicant
ON FROM WORKERS' CITY '�?� +�s ZIP % CROSS ST. d
COMPENSATI INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ++ TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER '�{ q/"Q C O. ?� 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 ADDRESS6b2Q5 f [CONDITIONS
so as to become subject to the Workers'Compensation Laws. r DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
App
CITY ZIP S CONST. C
Date A licant ARCHITECT t-�U CLASS N
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ' ✓` (/
4
Exemption, you should become subject to the Workers' SS Y 1 VALUATION
ADDRESS Compensation provisions of the Labor Code, you.must forth- r / VALIDATION
with comply with such provisions or this permit shall be Tp 13) $
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLARATION qqLO " LIC•
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
LIC.
$
(commencing with Section 7000)of Division 3 of the Business CITY CLASS
and Professions C andm lice a is in full force and eff ct. DESCRIPTION OF WORK
4 01 FINAL V
License Number. Lic. Class SWIMMING POOL P DATE , '09
Contract a e e a SPA p o
SO.Fr.
P�I am exempt un er ec. SIZE
f lqu
B.BP.C. for this reason ELECTRICAL a Oj 0 1,2 A
Date:
Signature Steel &Conduit Bonding # o 0 0 0 0 3
g Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING I ° 3 7 Q 5 0
I hereby affirm that I am exempt from the Contractor's License ° ° 3 70.5 0, 5
Law for the following reason (Section 7031.5, Business and
Professions Code): Gas System O 2.2 2'°8 8
Gas S
' I, as owner of the property, will do the plumbing and Anti-Syphon �9 0 3 q
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL # 0 0 0 0 2 1
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater ( o1 07. 1 0
CONSTRUCTION LENDING AGENCY °
I hereby affirm that there is a construction lending agency for5
APPLICANT' � TEL. / o o 1 071 0 t�
the performance of the work for which this permit is issued (PRINT) (� ( NO(�(J ( �
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS !l Q o222-88
&-�C
Lender's Address `
IFeeRJ r v
I certify that I have read this application and state that the P.C.Fee$ Permit
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee AV—
mechanical
and plumbing construction,and hereby authorize Investigation Fee ,��
representatives of this Count to enter upon the above- Total Fee
m Toned ropert f r i pe ton purposes.
s
Si ature of App!cant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE