HomeMy WebLinkAbout1066 (10) � insurebor�ffcertificatte of Worke sr�Compensatonensuran g'f APPLICATION FOR COMBINATIOIV SWIMMING POOL� PER19A1�°
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or c certlfied r.opy lhereof(Sec. 3800, Lab. C.) 76A2GD
) 1 CC67U(:i/Hal . . . . -
� Pof�cy No. �� t� Company �t.�.�,(o� �l-�C�r.t'.$—y COUNTY OF LOS ANGELES
��.r.;ertified copy is hereby furnished. BUILDING AND SAFETY
Certified copy is filed wit rhe ount buildi ec- FOR APPLICANT TO FILL IN BUILDING /
ADDRESS �(J� �p�,
Tion deparfinent, BUILDING ' i �
Dat� r ADDRESS JF��p ua {OCALRY
-��-Applica t � _
NEAREST
CERTIFiCATE OF EXEMP 10 FROM WORKERS' CITY ZiP CROSS ST, '*—(�'� � , p
COMPENSATIO f SURANCE �/ SIZE OF ASSESSOR � ��
TRACi �7:7S��J� LOT I.OT NO. ��� MAP 800K PAGE PARCEL
(This secfion need not be compl d if the permit is for one � �� TE� USE ZONE MAP
hundred dollars(5100)or less.) OWNER NO. Fj'�+�— d'j•' �p i`� NO. �� ' �`�
I certify that in the performance of the work for which this 9'\N
SPECIAL
permit is issued, I sha�l not employ any person in any manner ADDRESS .a�l�(��}� CONDITIONS
so as to become subjecllo the Workers'Cornpensation Laws. DISTRICT STATISTICAL CLA55 TYPE
CITY ZIP PRpCFSSED BY
Date Applicanf ARCHITECT O TEL. �/n� CLASS NO. � CO�
NOTICE TO APPLICANT: 1f, after making this Certificate of ENGtNEER � No. ��(p()�.Cj 1V � `� ��,
Exemption, you should become subject to the Workers' /'
Compensation provisions of the Labor Code, you must forth- ADDRESS /�f?' y (, 8iyr� VALUA710N
with comply with such provisions or this permit sholl be iE� ; ��j�f ``� VAlIDATIQr�y
deemed revoked. CONTRACTOR �y�/ NO.e�� „� �„�s°,�J -------�
LICENSED CONTRACTORS DECLARATION �j ���
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRF.SS S"'� p.S NO ` 5��2„5
(commencing with Section 7D00)of Division 3 of ihe Business �,�'} � ���' �E �"� s
CITY. �.�rJ`( �S-G-r'�""�.✓ CLASS
„ and Professions Code,and my liCense is in full forCe and effect. DESCRIP?ION OF WORK
FINAL
� License Number �5���� Lic. Class �s� SWIMMING POOL DATE ;� '� �, , ,^ a, `�C� � ��
Conlractor � i �'�'' Date SPp FINAL .;� ;�' o � o ;; � � Q
SQ.FT, O
� I am exempt under Sec. SIZE BY � j � � � � U
B,&P.C. for ihis reason J � 4 7 �
ELECTRICAL � ^ � '
Dale: `� ' . � �_, � � `, U.
��ic�r`�h c,��u�= S'c�r c. i; ;, ;> •t d. c -1 a
Sign�ture Steel&Conduit Bonding '� �.. W
Conduits, Conductors, Equipment L].
51NGLE FAMILY (�
HOME OWNER-BUILDER DECLARATION �
PLUMBING � � .,,,
I hereby affirrn that I am exempt from Ihe Contracror's license
��" Law for The following reason (SecTion 7031.5, Business and p-Trap
Professions Code): ;4j'� � �
Gas System //`�
}. � I, as owner of the property, will do the plumbing and Anli-Syphon v
electrical work. I,or my emp�oyees with wages as rheir • ' ` C�
t'; =^!s com^^�-_'_.- o� u iicensed conrractor will do oH MECHANICAL
N�„�����,�,
o}her work and the structure is not intended or offered ) � " ' '=!?();j
for sale (Section 704A B&P Code). Swimmin Pool Heater � �)
9 �_� ,. c: e_�;?v�{�
CONSTRUCTION LENDING AGENCY w
" ��s. c
€ :, �= c.�
I hereby affirm that there is a construdion lending agency for APPLICANT TEt. �`
;`, the performance of the wo�k for which this permit is issued (pRMT) NO. ' �
> (Sec 3097, Civ. C.). 9,f � �:'J j /, ��
lender's Name ADURESS � �i � %c � o � -j
Lender's Address � ' ,a i� �.-. �i ,� 1 � j �'y 5 J,� �
P.0 Fee S Permit Fee \ � y e.
I certify that I have read this ppplication and state ihat the ; , . , ,� „ <
� ' ❑bove informntion is coned. I aqree to c om pl y w i f h a l l C o u n t y ����'� F �1 � �• �,, F �` � � `��% �1�,�,�
.' ordinances and State faws relatiny to building, electrical, � '•J� .'�-.�-`.-� Issuance Fee �� ��'j :; ` �
; < mechanical and plumbing construction,and hereby authorize �n�esrigor�or,Fee , :F �'��J'���
�� ..... . .
� repr sentati� s o this Cou y fo enfer upo� the above Total fee �\ � ' ` ' •
ment ned pro erfy for insp ction p rpo e� ,
� � �
Siyn re of App' nt or Aqenf Da�e SEE REVERSE FOR EXPLANATORY LANGUAGE
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