HomeMy Public PortalAbout9641 VAL ST_Swimming Pool__ SAJIION DECLARATION / ' 'If
hereby t I haver certificate of concept to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT I(fl
insure o ate of Workers Compensation Insurance,,
or a cerh thereof (Sec 3800 b C 7Wn '
CE076(3/04)
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
F1Certified copy is hereby furnished
`�-y. FOR APPLICANT TO FILL IN BUILDING
pQ 1
Certified department
copy is filed with the aunty bwldinpytspec ADDRESS _
/`�hon department fes'/_�/P/J BUILDING
A ESS LOCALITY
Date Applicant / NEAREST /J
CERTIFICATE OF EXFMPTIO0ffROM WORKERS CITY ZIP CROSS STSIZASSESSOR
COMPENSATION INSURANCE TRACT LO LOT NO MAP BOOK PAGE PARCEL
(This s lion nod not M completed R the permit IF for oM TEL USE ZONE MAP
hundred dollen($100)or los ) OWNE NO NO
I certify that in the performance of the work for which this / 1 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 CITY ZIP M
DISTRICT STATISTICAL SS TYPE PROCE D BY
6 M l C T
NOTICE
T if a t ARCHITECT OR TEL L yp
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO 0
Exemption you should become subject to the WorkersVALUATION
Compensation provisions of the Labor Code you must forth ADDRESS �Qu.'� pro VALIDATION
with comply with such provisions or this permit shall be TEL f
deemed revoked CONTRACTOR ND �(irlf ' AoV
LICENSED CONTRACTORS DECLARATION ,
L p
I hereby affirm that lam licensed under provisions of Chapter 9 ADDRESSJ �� f
(commencing with Section 7000) of Division 3 of the Business CITY �� LIC
and Professions Cade and
yymy�llicc�es.snse is in full force and effect CLASS
DESCRIPTION OF WORK //)��
FUNAL
License Number 3/,SOK/ Lic Closs�� SWIMMIt.1Gy00L INY//-� - ATE �•' `
sem— --j ►- C'
p SPA w/7y a
Contractor Date � S �� / FI 0
I am mpt under Sec EFTJZ OF
B 8P C for this reason ELECTRICAL U
Dote Steel S Conduit Bonding 3 4 6 7 2 A CL
Signature Conduits Conductors Equipment Z
SINGLE FAMILY # e e e e 2
HOME OWNER BUILDER DECLARATION PLUMBING ,
I hereby affirm that I am exempt from the Connector s License 1 e it 07. 1 0
Low for the following reason (Section 7031 5 Business and P-Trap 0 7, 0 z
Professions Code)
Gas System
as owner of the property, will do the plumbing and Anti Syphon
electrical work I or my employees with wages as their 0 S20-86"'20`86
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered , ;R 4 6 7 3 A
for sale (Section 7044 B&P Code) Swimming Pool Heater # e e s • 3
CONSTRUCTION LENDING AGENCY i
I hereby affirm that there is a construction lending agency for APPLICANT1 - 370,5 0
the performance of the work for which this permit ❑ issued ) NO �%6� - 3 7 0 5 0
Lender s Name ADDRESS C 0520-86
Lender s Address
P C Fee S /Q Permit Fee 360,004 ,
certify that I have rood this gree to
and state that the ,
above information is correct I agree to comply with all County � 10 ,50
ordinances and State laws relating to budding electrical Ixuance Fee ,
mechanical and plumbing construction and hereby authorize Invisvigonon Fee _ �O S�
re entahves of this County to enter upon the above Total Fee s ♦ .
enti ed property for ins eUion urposes
6
9-Wre of App icon,or Agent is SEE REVERSE FOR EXPLANATORY LANGUAGE