HomeMy WebLinkAbout1439A 1440A (8) WORKERS'COMPENSATION DECLARATION . � {�
I hereby a(firm thot I have a certificale ai consent lo self
insure,or a cerrificate of Workeri Compensation��5��a��e, � � APPLICATION FOR COMBINATION SWIMMING POOL PERMIT - ��
or o ceriified copy ihereof(Sec..3600,Lob.C.) ��� �t6a2os� � � � . .. . � . . , . . . .
U� CE876(3l8d)
Policy�No. `�� Compony � COUNTY OF LOS ANGELES BUIIDING AND SAfETY
OCerfified copy is hereby furnished. � � - � ' � � �
� FOR AP I NT TO FIL N BULLDING A � �
Certified copy is filed wirh tha county building inspec- qDDRESS �
tion 9�ep°f Iment. BUILDING , _�, r/� �' ' '
/,�/(� A�ORESS� -� LOCALITY (�V(.(/(
Dale_���C`/ / App e � . ` � NEAREST � .
' � CERTIFICATE OF EXEMPTION FROM WORKERS �� CITY ZIP � . ceD55 ST. .
� � � COMPENSATION INSURANCE � �� �7 5¢E Of ASSESSOR .' �
TRACT�C� L LOT NO. Z MAP BOOK � PAGE PARCEL
�(This saction na�d not b�eompl�tad Ii Ih�p�rmit i�for ona TEI. USE ZONE MAP
hundrod dollars(5100)or lo�s.) � . OWNER No � • tap. - ��` �
I certify thot in the pertormonce�of the work for whith this . � . SPECIAL - . .
permit is issued,I sholl not employ any person in any monner AODRE55 �. CONDITIONS �
so as to become su6jec�toJhe Workeri Compe�sation Laws. � � DISTRICT STATISTICAL C1A55� .. TYPE PR ESSED BY
CIiY ZIP � - . .
Dcle Applimnt ARCHITFCT OR TEI.' C�IASS•NO. -
t.OT{CC TO APF�{C.",T.T: If, �flcr n-�u:.iny Ihis Certi�icoia Gf ENGWEER _ .`) NO. �(�"/�7 �� �J
E:emption, you should become subject to the.Workers' qooREu Q�En VALUATW �� � � � �
� ,,
Compensoiion provisions of the La6or Code,you�must for�h- 6 � N�� �
wilh comply wilh such provisions or ihis permil shall 6e . TEL. _ - � . VALIDATION
deemed revoked. � � ' COnIiRaCiOR Yl'� 1'�.QL.No 2.�,� �$� � � � ,:� Q j O A
� UCENSED CONTRACTORS DECLARATION �� - qoDREss S� ' NO. '� � � Ff a C�
J here6y attirm that I am licensed under provisions of Chapter 9 ii� j . . � . � ° °�2.�� .
(commencing wiih SeUion 7000)of Division 3 of the Business . .. � _. .. . ,� .. - • _
ond Rofessions Code,and my license is in(ull force and effeU. CITY GLA55 Cy� . •' :�'_ , � � ��l q � j
�f rIc�-nI FIHAC�.
� DESCRIPTION Of WORK
'License Number u3�1'i Lia Closs � SWiMM�NG POOL . � DATE V � �- ' , -0 Y� C-S 7 �
�14(,Okl a
-....CoNracbr rnRU173 R�T7CS Dale - SPA � � - - M• �� ,5 � �
FINAL
❑ so.cT. sr 3 • 1 d F.0 0 V
I am exempt under Sec. SIZE ���rl j �v
B.BP.C.ior ihis reasan ELECTRICAL . ... . , .. �/�// ��y/� �-� �- �cn+.� �—c�i% �
Doic ':. . J"' � L`i'"��� W
SignoWre � �S�eel 8 Conduii Bonding - � - d
Condui�s,Conductors,Equipment `�,��C��� . Z
SINGLE FAMILY ��y, _
HOME OWNER-BWtDER DECLARATION PIUMBING � r'} /_ � /j�J`O• �y
I hereby alfirm tha�I am exempt from the Con�roctor i Litense � � �J (F �r . . �
Law(or ihe following reason(Sectron 7Q31.5,Bus�nass ond - � � ��� � �� � � `}Q�•..�5 1T,4a1'" � � . -
Professions Code�: - . - P"TfOP ��
Gas Sysfem . . . .. �•-�Z^ S`�..
� I,as owner of ihe properry,will do ihe plumbing and An�iSyphan � � �
electrital work.I,or my employees wi�h woges as ihair , , , _. . _ , _
sole compensa�ion,or a licensed confroctor will do oll MECHANICAL - � � � �- �
oiher work and the ztruuure is not intended or offered
� for sale(Section 7044 88P Code). ' � Swimming Pool Hea�er � � � _ . . , -
� � CONSTRUCTION LENDING AGENCY . ' - � , �� • � .
I hereby affirm that ihere is a construuion lending agency for AP���NT � TE� .� � � ' � ,
ihe performance of ihe work For which this permit is issued �PRiNt � NO. � '
� (Sec.3097,Civ:C.�. � .��; �. � .. . --
.Lender's Name . ADDRE55 � � - � � �
Lender's Address •� ' � �'
� - P.C.Fee f ��/ Pe.mi�Fee- '� ._1;... ' .
I certify ihoi I have reod this application and ztate that�he � � �
-obave informatian is mrrecL I ogree to camply with all County . . O � •�"S t �
ordinances ond Stale laws reloting to building, eledrical, Issoonce fee � � . .
_ mechanic and plumbing cons�ruc�ion,and hereby au�horize �n�es��garo�fee � - � � -� - . . . . .
repr en e of this unry to enier upon �he obove- � - � imalFee � � �
me u pr per y lor� pe tion purposes. � . . . . . . .. .... ._ .. , . .
5gnowre o(AppGm� or Age�� -� - _ . SEE NEVERSE FOR EXPLANATORY LANGUAGE
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