HomeMy WebLinkAbout1299A 1431A (6) �, ; t
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. WORKERS'COMPENSATION DECLARATION � �- - � ��- ' �-:-;.-: � � _
i hereby affirm that I have o cerrifimte af conseN�o self �
. insure,or a ceriificote of-Workera`Compensation��s�,e��e, � APPLICA�LQN FQR--COMBtNAT1�N-SWIMM1Nf POOE'RER11�iT ..
or er�ifi d coF thereQ,f(Sec.3800,tab.C.) �� � �fiAppg - - - - ��M . - � � � � .
��.FsH�2�2sf}} C 613i8d1 �{
Polity Na-> Campany „��3. � ���r _-C�UNTY OF LOS-ANGEEES BUILRING�ANQ SAFETY
���ertified copy is hereby turnie e�-�_ _ . . .. . -- .
��/ � - BUIC�ING r�. ('1� ��._. .
�Jy,..Ler�iSed mpy-is f�fed wdh fhe counly 6oilding inspec- - �-- -FQ�AppE� T F N - ADpRESS� ,� `S� � � - �--� ��
T..� t' n departmenL - .__, BUIL�ING. � . �r=-.. .� .
.- ' ` .. ADDRE55 LOCALtTY
Date��-�.Applrcont NEAREST �
— CIFY .� _ _ ZIP CRO55 57.
CERFIFtCATf OF EXEMPTION RO WORKERS` S�ZE OF i� ASSESSOR
� - COMPENSATIpN IN CE - 7RqR a l0T l0T NO. d� - MAP flOpK PAG_. PARCEt �
- (Thi�sacf[nn nved not be comple►ed tf th•permif Fs for o�e iEt. Z� hnAP-- r1
. hundrod doilon(i100j ar�leu.J - � - - OwNER C - Np.. - �y . _
I certify rhar irt the pertormance oP ihe work for which ihis - �pp� . � � .
permif is issued,I shall not employ ony pe�son in ony manner AWRE5S /. ��`Q CONDR16NS -
so as to become subject to the Workers'Compenwiion Laws. -- - DISTRICT SFATISTKAL CtA55 TYPE - PROCESSED 8V �
CITY ZIP �Q ���55�.�� CIXJ57. � 1
Dpte - AppiicoM � ARCHffER TEL. ' �
� NdTICE��TO APPtICANF:.if, after making this Cerfifimte of EhtG�NEER �� No' . .
- Exemption, you shookd-bemme-subjecr to the Workers' -/ ir F yµ�µnpN . .
-Campensation-provisionsof-the"Labor£ode;you-mustforth- A��- - ' YAL4DAT{ON�-
� with com 1 w�th such p l. �! �� �a (� - - .
p y provisions or ihis ermit sholl be �����
� deemed revaked. � � -
..LICENSED CONTRACTORS DECLARATION A�S s� E�. Q G��� - . � .
. 1 Rereby affirm ttwt I�om licensed ueder provizions nf Chapter 9 ��� J � � - � -
- (armmertcing with Section 70Q0)of�ivisio�3 of the Business e1TY - CtASS S� � -
' and Professions Code,and my license�5�n fut)#vrte orxl effect. ����� �w� � - .
�1�rtI FINAL ;
.Eicense Number��Lva Ctoss� SWIMMING PQOL �J � -� -
. . .DATE .. . }. '
��'"�"�}., a. +
.. Contractor��� ��l_l� ppte�_� �A „ ! T � FINAI � .., � �i
5c�.fr C / er �1 c v,v A
�� f am exempt unde<Sec. - SIZE T � � - - - � _ - .. � �
. 8.8P.C.for this reason ELKTRICAL . � G�����f^ .. . ~• � � •G� Q _3
Date: �r�_ . . � �. F 4 4.��r, �
� Steel 8 Conduit Banding �bq� 0- �,
- Signature � , z .- a �w z I
. . Conduifs,Condudots,EquiQment
. SWGLE FAMIIY -
.� HOME OWNER-BU1tDER�ECIARATION MUMBING .-� � -- �� �r Q� ��? ;
� i hereby affirm that 1 am exempt from ihe CoMrocior's License ._ . - � - � � ;
taw-fm the fotlowing reason(Section 7031.5, Business and P-Trnp . (�� � �� -- - - -�
Professions Code}: �7'} ,
cos System kfFi �,�yt�iQ a
. � I,as owner of Ihe property,will do the plumbing and Anti-Syphon ��_� ��,^�� _ - . . . j
elechical work.I,or my employees with woges as their _ ! �., � . . � . .
sole compenso�ion,m a ticensed cantmctor wilt do oll h�CHANICAt �.{X - � a
other work and the structure is not intended or oHered � . - .
for mle(Section 7644 B8P Code). Swimming poal Neater � � . � . .
CONSiRllCTIQN LENDING AGENCY '�.
, I hereby affirm ihat fhere is a constraction lending agency for - - - t i � k h �i
� �he performance o#the work for which this perm�t is�asued �PRM� . Np�(j(� � . - ... - {
(Sec 3097,Civ.C.). -__ .. -�°° --= �
- Lender's Name . AODRE55�� l!J r_? !fe. �l��.f..�_Cl9� � � � ° � / e'.�1 �
� tender's Address - p.0 Pee F "1 \Y:7 �Permit Pee 1�� � � � � • ✓� �-` '�
I certify tbot 1 have read�his opplication and srote thot the _
� obove informotion is[wreC[I ogree fo mmply with all County - � - , . � � U'/,[''Y--�C '
ordinances and Siate laws relating to 6uiiding, electrical, iswonce PK . . - -
mechaniml and plumbing mnsiruction,ond hereby authorize �nvestigae�on fee � � �
rep�esenimives of fhis County to emer upan fhe above- � Tatal Fee - : �
ment�oned properiy for�dion purposes. - i
��._�� � �=a�� l
— y- tE e�ot.4pp�ka�i o.Agenr Date SEE REYERSE FQR EXPLANATORY LANGUAGE � � � �
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