HomeMy WebLinkAbout0829A 1061A 1062A (4) 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 � � �_ ` .
' Q o i.o!b �o tr,a p ^� ° � ' �-'��� '� �'��.'�-c.>° 2' a o i° o N.. � • _ _ 1 -�.
_. " .Ln ` o ° �, �i'v'ct"'`.c . TovN� EN -r.a:: > Uv;a � iU - �.�• ,%
:, o cv c o.c cv o a, c 3v�• or . '� 3 0' -� m o c �., a.. _ - - -
, " ' ��» n, c c � > e '°'c '` - � ��' .�. o a '.ay `•.
J v � � � ,� c a 3�c o v- ,�.. � �. � _ _ .��
.. ..Os oco�� '" £ oro � - �L „ e � A.c,�;o3E � `'y'���. ;�i ' : ' � "
. , ' � f:�'�,CN L ��C 0=.p p ._ T�� [ � 3.� d ,N_c a-. �o`..0 3 c. � .: - :� _ `/
� Q� .o_.� ,� E N �o `.-. ^` o ..',� E_�U.o u�� ��� a:�o U,c v �: � � . W '. ' 'f
>_.t o � 'S o.a � ., , o c;, � i ►- r
' Q �«.m.>, �; _ b c m m � 0 3 c a a o .n `. .:a"�-.o a , 0 _ _
'.uG;�� � .Q '� ,.�L'� C � ° _` 2.«H� �.qO�y . .�_`LNo..� ` � Z � _ _ : - � ' �i
p-.� � ° � c`, o � Ga� °o �ro _ '_°' ° ,o.'° '"amo_ � u� � . �n :, .
c , �• o " a y • u; p •c:o c c �` �• �-� oe ..
w d o o � �r�U. � � c ° c° = o � o 0 3t G'�:'�'-o'�� �ac oio`u o � v� : _ O � - �
E � c � r'c c a� : c �
� V ` Fu � � xoo ayyVa �. y �. . t�'- do � c - - • -. -
� E,o „ a ; e � a�•O �, av � t 3° c ` ,rz: - o� � �o N �v 3- w
- o .c c o ,;v'p o � ` _•t E c oa a._-.o - "�� c a � c O a , ' -
��' 'o o � �, E o .- o m ° c �• ,,, o '" >� c ; �� .n -
- CO'S•�n.� � �C:6 �t K ��' �G v c �n Q O G o �-c F. o i� w p � o V � = - ' •- -
; a; :
� o -� � c..u� Q �?a u °' � �°' >' �, c ro ,o . �,:� �,� cis ;, • - . -
�: iz'= '�,o:` -V`, °`-U +apa ��c „ coaao3 �'-0: �� 3.,�', c,3E;'3 „ � oi r' .
3 E•• a E �ah.� o � � �'i-� o ` Na °'� ° a � ao:a o- ''-+ o'` ° ' �I -
. p :.: 3� a-o o.°c�!^o �= c u o �.°Jc w c o F � H.c o a� o= `� N N U " ; E� : - . -
° �:° °-� d o n b°.>.a` °� � „ N �s � � " o_ 3,v c v °' ° o : _ - - ' • .
.. �'�:'� � a��'o �V �'� = � 2mo >'��., Ej .O'co rno'�-'aaa '�i � ' - - _
- =' c L � �' v `� o «v? .`a❑ y y c� ° > � °'��b °a�,` '... N O.r v � o �. . �. _ _
� � P� � � � L � �'ee `c °' 3 a� 0 3 0 � � �;u�a� .c.� b � a , ,. _ _ � � !
L u � d a. � � O N �� O O d �j � O E L � O CJ J '�... i O N p �« • � O� �[ l "' •'
� _ - c� o cEUh � r. �� 3 c .�� a.c �..o.a` ; 3; I o. . . - i�
. � � _ I .� _ I- ; j I ; ' -_ " , i : ;r..
�- - - I- -- ;- .: .; , _.. _i __ _ _ _.. . i_. ,_ .'. . �..i. ,,
i ,— '..` i . ' .� -' • - - �-r ' I( � ! �
� � � _ � -' '.' ' `r?�/ . j �� -_ . �l-- i ; i
� � � I C' . <+ `t `- r•� � J'=y !, , /. .'� I, , ; ' � - � �
„ u, � ,� ' � �` ' i ' �'�-J,` ; ; _ ; , , �
� Z I � r 'I '/' -' ' fr. '/.' �'. ,/ : � I � F , i _
N , �r � " I �/ I - - -- _ - , , I R
a � � - ' ; . ; �:' ;, '`:- :.-- -- , _ � � ;
: t ;. � -`�.,: � ; ; �. � __ � . . ;--- - -
� � - •, I � f i ; � �i
= r ; ,;_ _ ': .; � � � f! � ; �; . , -
� '; � • �:' : ' .� ' � I , � , - _.
� " ' '� � ; .� - ��
� , ' c � j � � ! Jj
; � Y', _ . � i, i . ,� -: i
Y ` : ; L! : ; � I ; 1 � � .� ; � �1..' .._.
� �., � i i ( � : ; '�•i i : ; ; � - -. �' � "i _"' _ ", I (i ; ; .�� �'
R ' � I ��� ;;� J. j � _:.� �. 1. _'i I i , i i - �' -�
.. . . . ._.. __ .. _ - - - ... - - - - - -
_ ..
> '' I -' i
i
�< I �, ' G _ 'i - '
; '� � ,: .� - + `' �
. ,�1 = ��
. :" . ; ..,,t , -
' ' - i
� �� Q, -i � �' ! �
� �- �- � j '; - -• - ,�., � � �
a ,. � -- W i ` , �
' O �; ' a � -- --
�. o� � � r, � 1
ti ,� i• 2 i. � � _.:� � �
w a �� ' � , i t� W
�: �. , �. � � � -,j Zz �
: � !-- " ' ' - - f > - o� z
"o I I i o !' • ` � a �� o W ..
- � O � I � G N �~ . � W �- �� u V Q �.• ¢ _ ..
� � � W I• � ..7' � Z p� S W W Z OC �I W Z ..
' I ' � ,��- �� � .z. • � '°x 3 v =% � t o � G
� O W a W � W v W �
I Z 0 a7 ,V' Z ' � ? R. N •C `-' N S W W j � 6.
1 I � 1 b4' F�: p O � W � • 1� W W V Q ~ IA O R
I� __ _ �. I " W � Z Q Q W Z W � Q ? W Q H
H Z. _� ..N. .�. m v O 3 .�'y' a w uW. t9 � W x t9 a�. d