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HomeMy WebLinkAbout0829A 1061A 1062A WORKERS'COMPENSATION�ECLARATION I hereby affirm that I have a certi(icate of consent to self � ��s�,e,or a cerlificate of Warked�omPe�Sa��o���5�.o��e, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT or a certfhsd copy ihereof�Sec.3800,tob.C.) �6q-op . . . . .—. . . .. . - _. .. , .. ... ... ....___. ...._ -_. . . .. _ �(;/� � � LE8T6(3/87) Policy No. d[lCompany � /l�(.� � COUNTY OF LOS ANGELES. BUILOING AND�SAFETY . � � ��Certified copy is hereby fumished. - � � - FOR APPLICANT TO FILL IN euaoiNc _ S3 Y �Certified copy is filed wilh tha tounty b�ildinq inspec- - ApDRE55 � - �ion deporlmenl. , it BUIIDING y . ��-�t)��c��� Y ADDRES$ �J f LOCALITY Date_C�C Applicom • _ NFAREST �/ CItY. ZIP. . CROSSST.- . '1 ER7IFICATE OF EXEMPTION FROM WORKERS' ' SiZE OF ,qss¢550rs � � COMPENSATIDNINSURANCE � TRACf I lOi LO7N0. I MAPBOOK PAGE PARCEI (Thi��acticn naad no1 bo complN�d if th�p�rmif 1�For on� � ... . . .. . .._ hvndnd dollan(SI00)or lass.) OWNER N0�., ..I`�7ZC u � r o� Q�g.3 3 7 1 cerlify that in tha performante of Ihe work fo�which Ihis ' � ���q�_ , „ . ., .._„ . permi�is issued,1 shall not employ any person in any manner AD�RES$ CONOITIONS - so as to 6ecome subje[t lo Ihe Worke�s'Compensafion Lows.� �� ��� � OISTRICT STATISTIUL C1A55 � TYPE- PROCE55ED BY - . CI7Y ZIF ' . CONST. Dale Applicant ' ARCHIIEQ OR ' ��� iEL. ��5�' NOTICE TO nFPLii,ntJT: If, aher making this Cerlifica�e of ENGwEER No. zR C) �� �. �'� � Exemp�ion, you should betome subject to Ihe Workers � - - VALUA710N , ' � Compensaiion provisions of the lobor Code,you�must forth- A�DRE55 � � with tomply with such provisions or this permil shall be .- - - EL �f� ' �G/V} -� � � � - --VAUOATION deemed revoked. . CONTRACtOR .NO. �Jvv • LICENSED CONTRACTORS DECLARATION � � ' ���� ' � - I hereby offirm Ihal l om licensed under provisions of Chopler 9 ADDRESS � NO. : s .. .. . . _ ......_. .... __ . . .. (commencing wirh SeUion 7000)of Divislon 3 of Ihe Business - ���' .- � � CITV � CIA55 ' . ond Professions Code,and my license is in full force and effect. �xRipilON OF WORK ' � � - � - -� - ' � ��j� _. .__. .. ...._.. . . FINAI / �. License Number�""✓ Lic.Class r� SWIMMING PODL � DATE ! �y/� � ,� �� � �� � ContraUorS�,�A SNC(� Data SPA . . . .. . -'- ...FINAI �.. . ..� . . ."O�i Z�i.F } ❑ � � 5(].FL . .. _ _. .. . .. _ . !Y _ ' .. � �. I am exempl under Sec. !'^� SIZE .. h,. • • e 2� O / B.BP.C.for this reason � ELECTRICAL . .. . .... ' .... � . ,'�.. , � U ..... . . .. ... -.' '— . ...... _ . ' I �c:5.�7' o � Daie: .-'.. _ n -- - .. . Signoture � � Sfeel 8 Conduit Bonding - - A/Q a � c 4 j,;;%.-`. «r•�_,� Conduits,Conduuors,Equipmenr � -- - � - , � �� � -- - - W � SINGLEFAMILY . �� . . �j _ � HOME OWNER•BUItDER DECLARATION PLUMBING � -� '�Ob9 - ��� � b't1 � � I hereby oifirm thol I am exempl fwm Ihe Contractor's License . . . .. . ._._... .. � . -� .' . '_ � � � . z law for the following reason(Section 7031.5, Business ond P_T�oP � . � - �- - -- .. � - � � � P.ofessions Code):-' �� . ' .� �� , ' .�� ' �- . . . GasSys�em .. _. .. . ._..._ . . . . . � I,as owner of the property,will do ihe pl�mbing and Anti-Syphon � �� - - �� � -�� � � . electriml work.I,or my employees with wages as their . .... . ... .... ... _ .._.__._....�.. .. ... sole mmpensotion,or a licensed confraaor will do all MECHANICAI -- - � �, � � �� other work nnd the s�rocture is no�in�ended or offered ' _. ._ . . . . .. � for sale(Section 7044 B8P Code). Swimming Pool Heoter � � � , . _ � CONSTRUCTION IENDING AGENCY - � " � - '� "��� � -�-� � �� I here6y affirm thai�here is a construction lending agency ior �E� ... .- . . . -q 1��E,� A Ihe periormance of Ihe work ior,which Ihis permit is issued . �pg�TT (Sea 3097,Civ.C.�. ( J �. ,. ._ _ _. . _. ._ .. � . . . . .3 � Le�dei s Nome ADDRE55 " -' �-- �� .._._ . ... __ _. .._'. __ _'.. . ....� ao � �l�� � Lender's Address p.C.Fea E Y� Permit Fee ►J s�l� - � - �� -�- �� �• e � � Ei li Q c=i I cerlify that I have read Ihis applico�ion ond stale Ihat Ihe � � . � obove information is correct.1 agree fo compiy wilh all CouNy .�.. 30, � Issuanca Fea � � �a L�—8� ordinonces and Staie laws relaiing �o building, electrical, � � � mechonical and plumhing construction,and hereby authorize ���esrgouon Fee 1 . � � � � - � � �� Q�2 A cPse��a�ives of this Coun�y lo enter upon ihe above• roiol Fee b me d e P P rty(or' peUion purposes. . . . . .. . .'` `. ' . . .. . . . . ' ��//-IC`� _ ���1`i.0 a ignat e of AppBwn or Ageni Doie SEE REVERSE FOR E%PLANATORY LANGUAGE� �'^�� d- � ..c !• o_c » c .t� .cv •� „ � � ,� b d d c.� p.`.``p�/ .t i-.� . . . ,�.. , " '^4 N.�,y� '^ - c:- m - � Q ° ° E � ��;' �o _.c _ `•��o ';� o _ aa� ...300 ��.� o - ` ° •o _ m � � �_ ` . 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