HomeMy WebLinkAbout0863A 0939A (4) WORICERS'-COMPENSATION oEClARAT14hF .. -__-. __.__.-- - ----- - .__--- .._-__._ .. . _ .�-
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� 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 -
- . . . . . . __ . . � ,
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