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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 � Z G t � �n G .�� � Z7 N � � ,� Gi W m C u V �� Q � ,p� � �n�� �- .L..��` � � R m p'a C u�r � p�� O v 0 � .� . ' 00 3 0 0 �o�� o.o y o c 3y^� ����� � �„`o_ >.a� o u a .° - •� ^ �C�i �N G ��'� y L-C j,O y �n•� F�� v��L > > d V a b � . U . o ��v . coccvo � m o3�• o:c � � 3 0 � m ea a - udo �°i�� doc �� amm _'r`c `o°v� - � .c ° oa � . 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