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HomeMy WebLinkAbout1066 (10) � insurebor�ffcertificatte of Worke sr�Compensatonensuran g'f APPLICATION FOR COMBINATIOIV SWIMMING POOL� PER19A1�° �•�...� I� 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 � o t o } � � � � Na d � � fl 9� l � A � � 1 . ,. 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