HomeMy WebLinkAbout0791A 2810A 2811A (4) WORKERS'COMPENSATION DECLARATION �
� 1 hereby afFirm thai I have a cerlifica�e of consent to self �
insure,or a cerlificaie af Workers'Compensa�ion��s��o��e, - APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � �
or a cer�iE�d copy ihereof(Sec.3800,Lab.C.) 7enzoe . . .. .... . .. .. _- . - .... . . - -. . . .. ..
� LEB76(3l8d) . "' ���.�
PoGcy'No. Compony COUNTY OF LOS ANGELES. . BUILDING AND SAFETY _
� Certified copy is hereby furnished. � �
a ti' FOR APPUCANT TO Flll IN ewio�ric 2 s�.�-�
Certified copy is filed with the caunty building inspea no�RE55�
tion deparlment. - BWLDING•7 �/J 7 �` � /�
.. AODRE55 ! 1f ) D �N / [i " ' LOCAUTV � _�-/•
�ate Applicanl �7 � NEAREST
CERTIFICAiE OF ExEMPTION FROM WORKERY � ��ir �I � .LP / . Gaoss 57. �
COMPENSATION INSURANCE tRACi 27� LOT� LOT NO. .Y ' AMP BOpK PAGE PARCEI i
(Thia soctlon n��d nol 6�compbl�d if th�p�rmit b for on� � �J TEL. U OniE�� AANP '
bundr�d dollars(StOo)or la��.) oWNER n-, .o���isa NO L�" �i y r , NO. .20 �� �
, I certify ihat in the periormance of ihe work for which ihis •) 2 y Z� � / ��C V�. SPECinI � � - - -
_. ....... ._..
i permit is izsued,I shall not employ o y person in am m �ar ADDRESSC..7J✓ � � O�v CONDITIONS �
so as to become subjecl lo the W�rs'Co pen ,(aws.� �a, � '� p15TRICT- SiATISTICAI C1A55 � iYi£ PROCE55ED BY�
,� ��1X�✓A Cliv /J Z�7 � � CONST.
' Doie�Applicont ARCHITER OR . . .. . -� TEI. ' .. .. v ���. ,. . -
NOTKE TO AP?UCAtJT: iI, ofler mokin Ihis Cenificcte cf ENGINEER NO. ,
_ Exemption, you should bemme subjxi to tha Workers' pD�RE55 (C� VAIUATroH -
Compensalion provisions of the Labor Code,you�musl forih• /+ 7/ Lf ,.�,�\ - VAUDATION �
wiih comply wi�h such provisions or �his permit shall 6e CONTRACfOR OGPN�N CQGS ��.Np.�([�'Z�f}7,!6 = "/ v�u ��
� deemed revoked. � - a _._... _ __.... . . .
� UCENSED CONTRACTORS DECLARATION aDoaE55�l Z�C}S /�t/�L�l/"`��tap_ S,�/YU
1 hereby affirm tha�1 am licensed under prorisions of Chapter 9 / ��� S � � - - . �- - � --
� (commenting with SeUion 7000)of Division 3 of ihe Bus�ness UTY �/%��� �� � RAu' �`�S3 - �� •
and Proiessions Code,and my license is in full force and effect. ��RiPtiOta OF WORK � " � ��7��. I H�
����/, . . . . .. ���y1 HNAL 1
�llcen:e Number
3S3f yo Lit.Class�;2� SWIMMING POOL rLJ�/_ DA1E ( ��_ . ' �• • o •'��
CoNmctor �w����� Dale�`311.[;[� SPA . .. �-. . ... ._ . IfGJ �FINAL ' - .� � • a 4��.Q 9 �
}
. . . � 50.FT. Sy i a.
` � I am ezempt under Sec. 512E . . . .. _ . � . .� � p • •4 9,G 9 o O
� B.BP.C.for this reasan ELECiRICAI . . . . . - . . � . .. . .. . .. . . .
i , Date: ' ��. ._... . _ _ . . . O
0�.10 58
�'Si nature � SIeelBConduit6onding . .. . �'. . . . ... . _'. ...'.
. �.. 9 Conduits,Cond�dors,Eq�ipmant � � p � �� ���- W
`�� SINGLE FAMILY ' / . ..... -- _ —.. . .�Z ♦—O Cv ,c I �P S L O A. a
' \� HOME OWNER-BUIIDER DECLARATION PWMBING � � � , � � '� �� -�� � �' �
' � I hereby�offirm thot I am exempt from Ihe Cantracror's Licanse . . _ ... . . __. . . ► (,�,'�.,L j,���_,J'O� ' f�•�r � 0 2 J � Z
law for Ihe{ollowing reason(Settion 7031.5,Business and v ' � � � '
P-Trop �� . � � .
;� Professions Code): - � � (i �ai t, d'T/3'�L � ' � ' •2�.�4�
. . . Gas System . .. . . ... .. ..... . . . ... . -. . . �
� � I,as owner of the property,will do the plumbing and Anti-Syphon � . ,'` 6 _ L1`
. eleUrical work.I,or my employees wifh woges os Iheir _ , _ . •� � - � � ���-. �� -�� .- -
, _ /
I �C .Q
� sole compensarion�or a licensed conlroclor will do all MECHANICAL 2''�J , � '
i other work and tha ah�cture is no�intended or offered � .. � ... . . � �.�2—fi�S
- - for wle�Setlion 7W�68P Code�. . � � Swimming Pool Heoter � - � � � CU!�LL=C f�`� . _
� CONSTRUCiION IENDING AGENCY -- �rL -I'��%��= �� �2 8�'� "
� fSece3097ftCiv.1�t there is o construU'on lending agenty for ADDR ' .{ Q����`i� ��/{O .► ....._ . '. .-.. . ..:_ . . .. �}• e •-• •j
APPIICANT TEL GUL� D�G�
- the performance of Ihe work for which�this permil is issued. pR�Ni �U73
� 1• � 1 7550_
Lender's Name E�5 / ,. }t� r r r,n=
q 1�+J . , , , � .. .I�].UC—FS�`
Lender'S Add�e55 p.C.Fee S //� Permn Fee - � � �- � ��� �
I certify that 1 have read ihis applicotion ond siate that�he � � � � '
abore informa�ion is correct.I agree to tomply with aIl County �- �/.(' Issuance Fee `� �
ardinonces and Slole lows relaling lo building, eleUriwl, ��� '
mechanic nd plumbing tonstruction,and hereby authorize Inves��ga��on Fea �- � � - ' � -�-- , �- - �
represe,n atl es of t ts ounty to enter upon Ihe above- Toial Fee �r >Q . �
meN"6 e�p f or nsp ction purpose , _ �
�l - _ U��
S�gnmure n fconi or ni Date SEE REVERSE FOR EXPIANATORY LANGUAGE -
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