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HomeMy WebLinkAbout0863A 0939A WORICERS'-COMPENSATION oEClARAT14hF .. -__-. __.__.-- - ----- - .__--- .._-__._ .. . _ .�- --- __ _..__. _-._.----- � I herebp affirm thoi 1 hvve a�certrf�cote nf mnsenr ro sel€� - - '��nsure,o�,a cert�lm4erof Wsoerkfers' ��t;a�F�S�.o��� - - APP!(CATION.-�.FOR-COMBINATIQN SWIMMING POOL PERMIT � �n .�l b.C.} :-�.. CE�(71J81) -- Pol y � . - Tcem��y - --.. . -..COUNTX-0F�tQS�ANGEIfS --- -BUIED4NGaND_SAFETY Cert�fied eopy.is heroby fumished'� � .- - -- -� � � - � - -- � FOR APPUCANT TO fILL IN Bunnwc � � ` ertif" d copy is filed with the unty i ins ec- aD�RE55 ��n J orf ent. _... _ _ -- &UiIQfNG.-.-'* . � � • �������(�},� -__. ..._ E55 L D01e �7 pplicanl - NEARES7 CERTIFICATE OF EXEMPFlON FROM WORKERS ��TM Z�p � c��� . - COMPENSATION INSURANCE � 51ZE OG . 4�. MSSESSOR . rrsncr ..`�3 Eor �or nio. -�c• MAp 80aS PAGE PARCEL (ThFs saetfoe ne�d nvt�6e compla/ad if tiw porn�lt is fw one . - 7EL. U5E 20rvE Mar h�,a.oadou�(s�oo}orlYst.J OWNER f1�� � r+o. rp_! No. —3 �3 I certify that in the perfsrrmance of the�work for wbich this - ` q SPECIAt permlt is issued,1 shall not employ any penon in any monner ADDRE55 �/U� CQNDITIQNS so ps to become sabjed ta fhe Workers'Compensation Laws. - DISTRtCT SiATkSTICA!CIAS$ TYPE pRp�55Ep BY EITY � P - CQNST. Date AppiimN � pR .�� 1`J.X��+—! (� OA55 NO.�j N4TICE TQ APPLlCANT;!f,�after making this-Cerr"rficate af ENG1 � a�' Ezemption, you shovld bemme subjec+ �o the Warkers' � � �-� YALUAiiO� - Compensc�tion provisio�of�he labor Code,you must forih- AoaRE �( (��()\ YAtIDAT10N , wilh-compiy with such prorisipns or Fhis permit sho44 6e �� � � S �� �JU � � deemed eevoked. � - � - LICENSE6 CONFRAEFORS DECLARATION �f� �` k hereby affirm that t am licensed under pravisions of Chopter 9 A��� � � - _ - � jcommencing wit SCCflOfl JOOO�OP QIVISIO�3 of the Business - `� ��' s - and Profession` .o y t4 e is-infuli€ ec{- ��TM � - � �� --- r (( ��R« �W�aK �a���;; ` d OR / u � Li N�m �� lic..Cla�� r SWtMMING 1'OOc � :�E`�b�f�f�� � �o • s •�j p� P /�Q 0 Conha . DaYe�� �0. � � FINAL � _ L � 1� SQ_FT. � a e C�(.t%(i U BY �y 1 am exempt under SeC. StZE � 4 '�G_.i�j y B.BP.C.-for fhis reason - ELECTRICAt. � � ` � ? g Date: . .. - Q E 1 7"�.�i �4ii Si nuture Steel&Eonduit Bond�ng - . _ � � � 9 � Conduits,Cortductors,Equipment - . - - � - SINGtE FAMILY � - � NOME OWNER-BUiLDER DECLARATION pLUM81NG . � - � � . I hereby aHi�m rhat f am exempt from�he Contrador's tkense - - - - Law fo�the foltowing reoson(Section�031.5, Business and p-Frnp . � � - Professions Code): � Gas System . - . � 1,as owner of the p.operty,will do ihe.plum6ing and Artti-Syphon � z_�y a G a _ e�ectrfml work_I,or my employees with wages as their . . .3 . - sole compenmiion,or a limnsed co�hactor wiit do oll- MECHANICAL�--� m• • •-a -other work and ihe sirocture is not intended or offered � �2� �('j Q - for sole(Section 7044 88P Codej. . . � - 'mming; I Heoter � - �-- . -� CONSTRItCTION�LEMDFNG�AGENCY �- - ' �,� � _ - g °L�I 3 U`v v ..____—.__._ _ .._. _. . 1 hereby affirm that ihere is a conssrucrion lending agency for a���� � . _ ��,�5��� _ the peAwmance of-the work for which this parmit is issued �pR � : -.(Sec.309T,Ci L. � 1 �/� -.. - tender's Na e �� qppp �/�' `-' '— � lender'sAddress PC Fee�;�--� �- . PermitFee- ��C.�1 .`� .. . � � � � i certify that t�have read.this appliwtipn ond srdte th[it the - . -�� . - above info.mation is correU_1 ngree-to<omply with�tl!Gounty- . —... . ..--- . . . ... . ..- . .�(} :Sv � . .. ._ _ .._. . ordi Stat Ipws reFaling fo 6uifdang,-elect�ical,__ __ - �ssu�ceFee _ .-.. . . - - -- - - � m nimt an plom ing construction,ond hereby authorize ��vesn9a�ian Fee � � -- .�/.�.o d re es � es f 11�s�Counry�to�enter �pon the above- � � � io�o4 Fee � � . �-. me ti ed pr rty r i spection purposes. � - .. . . L���� �- Sign. e nf Applicant or. eflt. - Dote SEE REVERSE FQR EXPLANATORY IANGUAGE - - . . . . . . __ . . � , �Q^V H �w t` 0 �n O�4 W L C 7 C u��i' F� G F'C .O m O ��s`p.. O .. 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