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HomeMy WebLinkAbout1743A 1822A ��_� .�_ _ _ ._...� . � y � -� WORKERS'COMPENSATION DEtLARATION � � I hereby affvm thai I have a cert�ficate�of mnsent to self �' w � insure,o a certifimte of Workers'Compensafion Insorance, ,ryPPL1CA�l� FQ� CO�lOiB�A,��IOH,,SWIM.NlIN�,..P.DOI;_PERMIT �� or a cert f ed<opy thereof(Sec.3800, C)� � �� 76gppg : _. . �;.� � � �„��.a.��_ J ..�E-875 11/87�e �� � �-" �_;.� � �' . PolicyNo`r"����3' Compa�y •'U7u`"" COUNTY OP lOS ANGELES - � BUILD(NC��ANA�SAPETY � Cert f ed wpy-is hereby.fum shed: - `"`�'` " - �� ' ' . " �-` -- . � _.,, _ FOR APPLICANT TO FlLUN:_� euaPiNc �./ � : �p� � ' Cert f ed copy�s 4iled with the county building�inspec- ._ ADDRES'- �.7�.S . .,a(y•?�Lf � fion department �.. r � ��BUIlD1NG J { ��/J � -. . -�--- - � 7 - . �A�DRESS J�j� ..-.(JC�{� � � lOClLLISY'. .�' . . Da1���APPl�cant����j-�'••.26� - . � . . - NEAREST .fL'-�.7�- _._CERTIFICATE OP EXEMPT.ION FROM WORKERS' CIiY - ..�,_ ZIP - CROSS_ST� �I,. _��,..c,..�-�,.rr Z�Z.✓-�"'. COMPENSATIOfJWSURANCE � 7RACY.f✓�/_i.a� LOT�� LOTNO t�C MAPBOR PAGE- PARCEC � (This.seclion nead-nDf be cQmpleTed if tha permii is for ona _ -TEL : �. • USEZON�; MAF . - - � hundred dollnrs{5100)or less.) � . � - pWNER�.. . . 1�� NO., y�� .- � Nd: �L�� �"'�` i certify that in the perfocmance of the work�for which ihs ., . - -- ��j.�G"<- SPECIAL - � -. permit is issued,I shall nofemploy any pe�son in ony manner ADDRESS_- - �/ � ��� CONDITlONS �-. - so as to become subjec}to the Workers'.Compensation�Laws. � � � - - �ISTRICT' STATISTICAL CLA55 TYPE PRO SSED BY �- - �- � CITY .., ZiP � CONST. � Date Applicpnt .. ARCHITECi Q �'f.. � 7EL ..-�/ ClASS NO. - - NOTICE-i0 APPLICANT: If, after making this Certificate of �ENGiNEER ��aG ,,.._�, ,.._�.�.r._..._.,._N0:�,3L``d � �Jy - - � Exemption,-you should become subiect to the Workers' � �� y�;�,_/'J .tr - 'V7CLUATION � - .. � _Compensation prcrvisions of the Labor Code,you musfforth .�+ORRESS a'rJ•�G(.�tGt.' . . - � ��� � ypy�T10N � with mmply with such provisions or this permii shall be . -. � N1��- �S� S ���j�i�Cf�� deemed revoked. CONTRAC20R- �J7 - � - -�- LICENSED CONTRACTORS DECLARATION �- y�i " � � - LIC.-„� �� - _ - �� I hereby affirm that I am I<ensed u de p ovisions of Chapfer 9 �-ADDRE55 eo.�Jfr �/ .. � ��� s��� � - `i,�7 , k ._ ��.�. . (commenc ng.with Sect on 7000)of Drvision 3 of the Business �C�7Y� -�.�4°7J�� - CLASS �..� - - ��' and Professions Code�and.my license s in full force and effec� �- . . .. - 4t s ei' �� . t3e-. ��y�' . DESCRIGTION OF WORK . - FINAI � � �� � � License_Number��"`�-' .Lic Cioss�`7� -SWIMMWG POD. .. . .. � DAT� , : � o e�( �j;y '��' ��`- Confracto � Date�� ..bPA _ __ ... . . _ v.� �-FINAL ' . , -.. �V ._. .. . .. r 6� � ., � - SG1.FT. �j 9� � - gy � � I am��exempt under.5ec: - SIZE �")"�L°��� �-- � y'. � 4:�.L -�� � w B.&P.C.for.ihis reasan � -- .-ELECTRICAL _ . . . _�j��i� � Date: � -� . - . � . .. ���C- .. � . Si nai�re - - -�- - � � $teel&Conduit.Bonding � � - . 9 ConduJs,Conductors,Eqoipment - ' . � � SINGLE FAMILY �� - - � O`�.�} (Si�" � �- � � -� - HOME OWNER-BUILDER DECLARATION - PLUM8ING - - �q' � - - - I hereby affirm that I om ezempt 4rom iheLontmctor's License - / g�� - Law for ihe following:reason(Secton 7031.5, B�siness and � P_TraP � � � ��e����(���}r--�"��^� � Professions Code): � . Gas System _ � -I,as owner of the prope�ty,will do ihe plumbing and _ Anti-Syphon - -- - . ..electriml work.I,or my employees with wages as.the�t . -�' . . . sole compensation,qr a licensed�.coniroctor will do aIl -MECHANICAL- � - � �� - other�work and the structure is not infended or offered � . . . . ��� �� : . ��- - -y � for sale(Section 7044 B&P Codel. .� S-wimm ng$oo1.H�ater � - - �� � .- � - - --�CONSTRUCTION LENDING AGENCY- � - ��- �- �-� - � - - � I hereby affirm thai there is�a conshociion�lendinq agency for qpp�ICANT�-- - -- � -TEL� � -r_S�b'�L,�`�� � � ihe performance o4 ihe work for which this permit is-issoed �pRINT! .NO... � , � - � � � (Sec.3097,Civ.C.;. . � � _ y�'� � � c�.s . Lender:s.Name ADDRE55-- - .. - � `/ t e i 5.,5G _ Lender's Address � �p.C.Fae$ `/,��•r++� Perrr�it Pee: � - 1 certify ihat I hove reod ihis applimtion-ond store�.ihot the . . - � �f��L.��'o . . . . obove informaiiort.is correcf.I ogree to comply wi(h ol�County -- � � .�(� U J,V� `�`�!-' ordinontes and.State Jows reloting to.�building, eledriml, - issuan<e Fee�.-- - . mechonicalondplumbingconsiruction,:ond.he[e6yauthorire Inves��ga�ionFee. . - � �represenitltives of.7his.County to enter upon ihe above- 7o1pl.Fee ..�.�C�i..i��'� � menfio 4{ed propert for'nspection purposes .d."ry :�. 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