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Home My WebLink About08_09_1984 - 2016 PEACEFUL HILLS RD . . . , . . , � -� . ��. �±✓� ' WORKERS'tOMPENSATION�ECLARATION � � - � : � �! I hereby affirm thoYi liaSe a cer�ificate of mnsent to self. . insure,or a carirf tate ot,Workers'�omPe�So�,o��,��o��e,� . APPLICATION FOR COMBINATI0�1 : IMMING POOL PERMIT� �� or a cerrif�ed copy thereof(Sec.3800,Lob.'C.� �ta2oe , . . � .. . . _ . . t ' 7ct-D2 ('t� ��,�. CF'875l11/81J . Policy No. �J� Companyr+zi«�� . COUNTY OF LOS ANGELES ''BUILDING AND SAFETY ' � � Ceriified copy is here6y fumished. � ., -�- � � . � FOR APPLICANT TO FILL IN eunon+c � Certified mpy is filed wilh the munty building inspec- ADDRESS d��i ��/ . fion deporiment. , , BUILDING � � - ADDRESS- LOCALITY � � Date� Applicant � � l�, NEnRES� � � ' CERTIFICATE OF EXEMPTION FROM WORKERS' '�� 7 �Ju(,� Ziv' . CRO55�: �Nt. , COMPENSATIONINSURANCE TRACTr7o�Jr7� S�ZEOF ASSESSOR , LOT LOT NO. � MAP BOOK PAGE PARCEL i -�This aaction na�d not b'e eompl��d if ths permif i�fer one iE�, u5E 7 E MnP y q - ' , undred dollars(�100)or le��.) OWNER NO.� �y3 � . r,o. D,.� JZ/ � I nertify that in the periormante of the work for which�his � � . SaEClql . permit is issued,I shall not employ any persan in any monner A�DRESS CONDITIONS - - so as fo 6ecome subjed to the Workers'Compensa�ion LowS. . - � DIS:ftICT_ STATISTICAL C1A55 TYPE P 5 BY � CITY ZIP ' ST. Dote Applitont � ARCHITER O A . . - TEL. /��„. QASS NO. . NOTICE TO APPLICANT: If, aRer making �his Certificate of ENGMEER C% NO.��r•(1� �� Exemplion, yoo shoold become subject to the Workers' �� 7 ? � VAWAiION � � � Compensation provieions of the Lobor Code,yoo�mu5f foNh- ADDRESS /iT 3 ZC!L O� O ' VALIOATION A with comply wilh such provisions or ihis permit sholl be . TE�• �S u deemed revoked. . � CONTRACtOR 333 � LICENSED CONiRACTORS DECLARATION ��' �-yJ /-/� � �� :�'•:•.49,�� I he�eby offirm ihat I am I�censed under provisions of Choprer 9 AD�RE55 ` NC: ,)v��?� s � _ .•5. . O x -(mmmencing wilh Section 7000�of Division 3 of the Bosiness , CITY - QnSS--�`S�' � � 4�a � y i ond Profeuions Code,and my license is in foll forte bnd effect. . - , -�` �� <;.Q 9'8�1 d � DESCRIPTION OF WORK FINAL License Number� �s� tia Class eS � �SwiMMwGPOOL . . . . - � � DATE �!—l�� ► ��6�.8�Q�6 A V �. ��'fi�,�� ' CoMracl � � Date � SPA ... . .. . . .iINAt . . � . , • - � � so.�r. er � C • • 1 7a50� W � I am exempt under Sec. SIZE - ' � ' ,y � 8.8P.C.for fhis reason � � . ��ELECTRICAL .. . .. .__ - � . � � : O��O 9�-�4 � . Z '. Date: � . �/ �. � Steel 8 Conduit Bonding � �;/ v �" - Signoture Conduits,Condotlors,Eqoipment LJ _ - ' SINGLE FAMILY � . ' .,�•�� ' � HOME OWNER-BU�LDER DECLARATION - �plUM81NG � I hereby affirm thoi I am exempt from the Comractor's License � . D '-- ' ' �.q , Law.for the following reoson(Section 7031.5,Bosiness ond '. � � � �- �� _ "`� . � . .. _ . .. _ _ ... _ --Proiessions Code): ._- . _._. - � P-Trap ._____. __ .. . . . �,J'�� ". . _. .. -. ._- -.. . . .. - � ---- ---- - -- Ges System . . i v i ... . _ . . . - � I,as owner of the prope�ry,will do tha plumbing and . Anti-Syphon �� . '� electricol work.I,or my employees with wages as their � . - . �• sole compensation,or a�icensed mntrocror will do all MECHANICAL - � ' - �� - � -� � � � ��. other work and the strutlure is no�intended or oflered - . . . . - for sale�Section 7044 B8P CodeJ. � � $wimmfng Pool Heoter � � -� - �� . . . ' CONSTRUCiION LENDING AGENCY - � � . � � I hereby affirm Ihat fhere is a conslrucfion lending ogenty for qppp[ANT TEt, � � - - � � - the performonte of the work foi which thiz permit is issued _ (PRMT) NO. ► ' � . � (Set.3097,Civ.C.). � - . - i lender's Name � - ADDRE55 � - � .... . _ . . _ i _ _ . Lender i Address i � � � � • � - P.C.Fee E Perme Fee � 'U v � r I certify�hnt I have reod fhis appikotfon and state ihat the ' ��.�� .obove iniormation is mrted.I ag�ee to comply wifh all CounN � � �- � - -/O •5--,\ � ordinances and S�ate laws relating to bailding, electrical, � Issuance Fee� V . . I mechonical and plombing tonstrutlion,ond hereby authorize �^•es�iga�ion Fee �S �i' ' , , , � representafives of 1hi5 County to enter upon the above• Torol Fee (� - � � ' � . � meniioned property ior inspecfion purpo5e5. � � � - � - � � Signa�ure o� limn�or Ageni � ��o�� SEE REVERSE FOR FXPLANATORY LANGIIAGE . � I i.. _ - - . . - � �o p x(n '-� p C1 � � D N { � O O ,�- m� � -- o� o . 9'0 0 ,D„ D D 'C -b,l n C� _I m -Ai ID/1 Y , Z '_ � �, . . � D r n �" n ymi �^ 7p �'n ]1 .-� .0 tl O -i �y � , .. � � m N m t = � 'v :r_ m =� � �,O •�t O -s ' r n � � �-- ^� � = A � � � � - � o � A �N n o �+ i� �o p -o i � ~ � (1 � T T 'v'� N � . � ._ -� � y� � . ,Q - m � An D - -. . .. 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