HomeMy WebLinkAbout1395A 2140A (7) WORKERS'COMPENSATION DECIARATION i ' � �7�
I hereby affirm thoi I have a certifimtPe of tonse���o self ' APPLICATION,..FOR�COMBINATION SWIMMING.-POOL PERMIT ��
insure,or a certifica�e of Workers'Com ensalion Insurance, - � � ��
or a certified copy�hereof(Sec.3800,Lab.C.) 76nzoo --� �-� � � � � --� �� � � - � � � � - -
�i-/7•� y��N� CE07613l8a)
Policy No�/O S�/.�Company r-'�^ � COUNTY OF LOS ANGELES � BUILDING AND SAFETY
� Certi(ied capy is hereby furnished. �
� FOR APPLICANT TO Flll IN aunowc r
�Certified copy is(iled with rhe munty 6uilding inspeo ' � -�- � � - � nDDRE55 1 S
, tion deparlmen�. BUIIDING • �
♦ A�DRESS IOCAUTY [ ��
Dale �r Applicont� � i NEAREST
CERTIFICATE OF EXEMPTIO ROM WORKERS' . � � ��TY b�4N�NA � Z�P CRO55 ST. -
COMPENSAiION INSURANCE � � � TRACT I I� LOT OF LOT NO. �I� MAP 600K aAGE PARCEL ,
(This��cfien nNd not b�cempl�tvd il the p�rmit is for on� � t/ TEt. / u5E ZONE mAv ^7 . . .
hundrvd dollars(5100)or less.)�- OWNER �r� �S' ��� NO. 0�-01 . NO. r 3 3 I
I certify thai in the performonce of the work for which�his ! �I� SPECIAL . �. . . .
permit is issued,I shall not emp�oy ony person in any manner ADDRESS � � CON�ITIONS
�so as io become suhject ro ihe Workeri Compensalian LawS.' � �- -- - DISTRICT - SiATISTICAI C1A55 T7vE PRp�E55E�BY �
CITY Q O Z�P - CONSi.
Dafe ApplicoN � ARCHITECT OR � � � TEL. � � � - �u NO. n �
NOTICE TO APPLICANT: If, aficr making this Cerlificate of EIJGINEER NO. `fl � -��1
Exemption, you should 6ecame subjecl to ihe Workers' " � '" " " "'- - " ' VAIUATION
ADDRE55
Compensoiion provisions of ihe Labor Cade,you mus�forth- //i� � . . VAtIDAT10N�
wilh tomply wilh such pravisions or Ihis permit shall be �� �� TE��C�� S ��` .
deemed re�oked. ' coNrancroa 'Y•- :
LICENSED CONTRACTORS DECLARATION _ uC.
� ADDRESS (j NO. �
I here6y affirm Iha1 I am licensed under provisions of Chopier 9 ^� ��� ��� � � � � ��
- (commencing wi�h Se��ion 7000)of Division 3 of Ihe Business�- CttY �C 'C�^T-"C1A55 . -- �
� ond Protessions Code,and my lirense is in iull force and effe[t. DESLRIPiION OF WORK � " '�� � -
FINA
. License Number lic.Closs� SWIMMING POOL � � UAT ��� , - ��1�9•5 A _
a
zE/✓L/I�Osc4f��,pP GovS7. Svn ' _ ❑ 'r {i. • ..�3 O
Contraclor Da�e FINA U
� I am exempt under Sec. SO.EFT. / Z .. .. . . ...eY�,� . �! � �9 1,3� a
. . �B.BP.C.for ihis reason I . . . .. . .. - � - � ' �-' O
e�ecre�cni Q,ee,t. .2.5�6G 9 '.< �q 1.3 3� v
' Da�e: i �,�.Cf/i/ . - .. W
� Si nature . . � Sieel 8 Conduit Bonding . .. - . . . . . ____ . . . . ��L-P.��b N
9 . i Conduits,Conductors,Equipment � �. Z
- _ _ SINGIE FAMILY . . . . . .. . .. ._ ....- .. . . . ,
� HOME OWNER-BUILDER DECIARATION PLUMBING � ' ' � � - -" �� � . - .�,
� I hereby offirm�hat I am exemp�from the ContraUor's license ; . . . . , _ . �
� Law forthe following reoson(Section 7031.5,Business and i P_T�op � � � ' � �� - �-�
. Professions Code): ' � � ��.�'� �,0 A
Gas Sysfem _ . . _.. . . . . _ . _ .
- � I,as owner of Ihe properry,will do the plumbing ond ' AniiSyphon �
� electricol work.I�or my employees with woges as iheir._ � _ _ . . , - �� ��-_ - - . W_� ���_� �`�
sale compensalion,or a licensed conlro[lor will do all MECHANICAL
� other work and Ihe strucWra is not inlended or offeiad � ' ��-- � - � � ���.� � � '���5� .
� .. ... . . .. � � -
� for sale(Settion 7044 B8P CodeJ. � Swimmiag Pool Heaier � __ . . . • o G L�J��c=.�
CONSTRUCTION LENDING AGENCY
' I hereby afFirm thol ihere is a constroction lending ogenty for qpp�ICANT TEL � � � -� " ' �9.� `5—8 6
the perfarmance of the work for which ihis permii is issoed ; (pg�NT� _ - ,_. . . NO.�� ,
(Sec.3097.Civ.C.). � ... . . . .
Lendel5 Name ADDRE55 . . .. . . . .. -.. .. - ... . . . .. .. _. .
Lender's Address P.0 Fee E ' Perml�Fee ��.h. � � � � -��� � �
,, 1 cerlify thot I have read Ihis applicalion and stale Ihot Ihe � � , • ' ��
above informa�ion is wrrect.I ogree�o comply with all Counry i,� -- - -� � iss�a�<e Fee ld��d �� � � �'
'ardinances and State laws relating to build�ng, electriwl, �
�mechanicol ond plumbing conslruUion,and hereby authoriie Inresi�goilon Fee , , , / �D ' ' ' ' ' ' ' ' � - _
representotives oF this County lo eNer upon Ihe abave- � toial Fea .7�,5 ' '
meMioned properly for inspecf n purp ses. I _,_ , . _ ,� � - � �� � � -�
X i��
5 oture ol AppGcan�or Agem Daie , f( SEE REYERSE FOR EXPIANATORY LANGUAGE
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