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HomeMy WebLinkAbout1576A �.�- '�.`^.r--�• _ :'�"^-� /� - WORKERS'COMPENSATION DECLARATION � . �—�` � 1 � I hereby a(firm ihaf I have a certiflcatne of�o�se���o Se�f ' APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � insure,pr a certhica�c of Workers'Com ensation Insuronce, or a cerhfied copy thereof(Sec.3800,lab.C.)� 75A700 ' - � - ' ' � � CE-875(il/BIJ � PoGcy No. CoR+pany COUNTY OF LOS ANGELES BUILDING AND SAFETY .- � Certified copy is hereby fumished. � � . FOR APPLICANT TO FILI IN p��Eu a7 a S �e��Cr Ceriified copy is filed w�th the coumy building inspec- tion deportmeni.. BU4DING ( �. ' ' A�DRE55 �S IOCALIN �C! /-.C/�L. ' Dote J Applimnt � NEAREST CERTIFICATE Of EXEMPTION FROM WORKER$' CITY �/ZiP �� CRO55 ST. U i' ' COMPENSATION INSURANCE S1ZE OF ASSESSOR - TRAC7 LOT l0T NO. MAP BOOK PAGE PARCEL � (Thla�sacllon nNd not M compl�Nd if th�p�rmit i�!or on• TEL. �.. � USF ZONE MAP , hundnd dollan(5100)or I�s�.) OWNER NO. � D Np, � I ceriify thot in rhe per(ormanca o(rhe work for which this ) /+� SaeCb4� . I permil is issued,I sholl not employ any person in any monner ADDRE55 � f•!^k .cI Li/�Q CONDITIONS • so as to becoma sobjec7 Io Ihe Workers'Compensation Lows. � DISTRICT STATISiICAt QA55 TYPE PROCESSED BV CITY ,:1i-r ZIP pZ/ CONST. Da1e A limnl P.RCHI7ECT OR 7E4 (�) CWSS NO� , NOTICE TO APPLICANi:PIf; oNer making this Certificale of ENGWEER NO. l v , �c�( , Exemption, yov should become sobjecl lo the Workeri � � � VALUAT�ON �� - Comp¢nsation provisions of�he Lobor Code,you�must forth• AD�RE55 _"�+� VALIOATION wilh [omP�y ih SUCfI pfOVi5iOn5 O! tf1�5 F12fmit sholl be �CONTRACTOR d ��� NO. �"I �aO deemed revoked. UCENSED CONTRACTORS DEClARA710N ���• I hereby affirm Ihaf I am licensed�nder prOwisions of Chapter 9 fADDRESS NO.� LIC, s (commencing wifh Section 7000)of Division 3 of the Business ���n, ttA� . } and Professions Code,ond my licensa is in full forco and effecf. �DESCRIPTION OF WORK Q HNJ1L ► V License Number Lic Class � � SWIMMING POOL DATE � � a Conlraclor Date SVA � � fINAI _�_ i' O SQ.FT. + !Y . W � � I�am exempt under Sea 5¢E � - � y� , B.BP.G Fo��his reason ELKTRICAL ? Dale: e � � Steel 8 Cond�ir Bonding �-I�� / Signoture Conduils,Conducrors,Equipmont � � � � SINGIE FAMILY , HOME OWNER-BUILDER DECIARATION PLUMBING ► � 3 I hereby affirm thaf I om eaempr from iha Controdor's License (n � 2 1 5 7.b A� .Law for ihe following reoson(Secfion 7031.5, Business and � �U , , P-Trop Professions Code): �� � � � �3 Gas Sysiem � I,as owner of�he properly,will do the plumbing ond Anti-Syphon e�ec�ricol work.I,or my emp�oyees with wages as Iheir � • •3 Q 5 0 sole compensation,or o Iicensed contracror will do oll MECHANICAL. ' other work and tha strucfure is nol iMended or offered ^ . . �' • °�Q Jr Q c=.i for sale(Section 7044 B8P Code). Swimming Pool Heater - �p�, CONSTRUCTION LEN�ING AGENCY . O 2� 6-8 4 I hereby affirm thm there is a construuion lending agency for ypp��CnNT Q +� TEL � ��.0 ihe performance oF ihe work for which rh�s permit�s issued �PRINi) yp. ' (Sec:3097,Civ.C.). � /� ( t � lender's Name �aDDRESS `� Li1�l� E'ri � �1���'�� . � Lender's Address � �.e Fes s ve,m��Fea c�G.(iN I cerlify 7ha1 I hova read Ihis opplimfion and sfate Ihol the ' obove inFormotion is correct 1 ogreo to comply with oll Counry i � Issu ce Fee �d•S U � ordinonces ond Siate lows reloting fo building, electriml, mechaniml ond plumbing construUion,ond heieby auihorize ���esi�ga��on Fea a^ , represenfatives of this County to enter upon Ihe obove- i Toial Fee -L�U.SU � . niioned prop �y 4 r i eclion purposes. � � /n� .! ..,�...�,r,� ,z 1��� j ' � Signawro o(nppGcont or nge Doie I SEE REVERSE FOR EIIPIANATORY LANGUAGE Y �_ ��__� . . . ..- -'.--. ..___._»,...�. --'.- - . _ , _. 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