HomeMy WebLinkAbout1430A 1689A J . t � , — -,s • -- .. _ . _ , ._ ._._ �
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WORKERS'COMPENSATION DECIARAiION
insurebor�afcertifkote of Workers'�Compensaiion��5�'�a��e`-� �� � � APPLICATION FOR COMBINATION SWIMMING POOL PERMIT�
or ac,gr�n ied copy thereof(Sec.3SOD,L b C.) �� �sn2oe � - -- � �- �� - � � � - �
,` GE876{3/BI)
Polic No.'��o-m¢any COUNTY OF LOS ANGELES BUILDING AND SAFETY .
� Cenified copy is hereby tumished. � BUtIDiNG
� y� FOR APPLICANT TO FlLL W � aooaess � ��� �f� Yl-1.3�eJ
� �� Certified copy is filed with the tounty building inspec--
1on de arfine��. . . BUIL�ING (� ���� �
l� "f��O� D ADDRE55 �}� r R Y1+4���n l^R^'t- IOCAIITY
Dolep���� � Applimnt ��`L� `��S• NEAREST �7
� CER7IFICATE OF EXEMPTION FROM�WORKERS ��TY� - -�R �fi�Lv. � CR05S Si. F �^'� K-l
- ����COMPENSATIONINSURANCE � SiiEOF n55E550R
TRACT 3�ti� LOS LOT tJO. MAP BOOK PAGE PARCEL
(Thl�sxtion nwd not b�eomplotad 11 Iha p�rmH is for on� T�.�j���, USE ZOtaE MAP �6� 3�33 .
huadr�d dollon(f100)or leu.) " � . �� OwNER ��J ��' �� �
I cenify that in�he performonce o(�he wark far which�his � 5���'� � � �� .
permit is issued,I shall nol emplay any person in any monner ADDRE55�,.l �Q L CONOITi0N5
so as�o become subject to the Workers'Compensation Laws.� �STRICT STATISTICAL QASS iYVE PROCESSED BY
. . . . CIN . . ZIP ��NO. CONST. L
Dale Applicanl ARCHITECiOR � � TEL (� ��
NOTICE i0 APPLICANT: If, aflc: mckir-y 7��is Cer�ificole oi ENG!NEEo � � NO
-Exemplion, yo� sho�ld become subjecl'to Ihe Workers' YAlUAT10N . .,
�Compensoiion proviaions of the Labot Code,you�must forlh• AODRE55 � � �+-1lJ . .. VAUDATION
with tomply with wcb provisions or lhis permit sholl be tE�" f ��
deemed revoked. CONTRACipR � i� � '���Z - � -
UCENSED CONTRACTORS DECIARATION � � � � � ���� �
ADDRE55 �{ �. L = � /�J( A.-.,�1 - . .
� I hereby of(trm that I om licensed uader provisions of Chopter 9 ��� v a �
(commencing wifh Section 7000)01 Division 3 of Ihe B�siness � ��TY �}.� � ftq55 ���,
, ond Professionz Code,ond my license is in full forCe ond eHect. DESCRIP710N OF WORK � f�ryµ _� � '�/ =�'� 4��A�
QC /� � '� C
License Number � �+ `�1 02 Lic.Closs=��. SWIMMING POOL DATE -� ��� o � �2� � a
. '��.�A-- �LL'���s Dote ��/� 7 SPA . . . � FINAL �I .. . � •,5 6.5 3 � a
Cor,rroctor , so.pi. l+y � . er
� ❑ � SIZE �J "'�� -c
1 am ezemp4 under Sec. • < 0 5�,5 3� o
U �
B.BP.C.for this reason EIECTRICAL - � �" O 9�9,�8 7 _ �
Dote: Sleel 8 Condait Bondiag � - � �i{; '�✓ ' � N
� $ignoWrg Conduiis,Conductor5.Equipmenl . Z
' SWGIE FAMILY � "� "� , . �
� HOME OWNER�BUILDER DECIARATION PLUMBING ��Z.�9� _
1 he�eby oifirm tNat I am e.empt irom Ihe ConiroUor's License .. � � . . . . .
luw for the(ollow�ng reoson(Section 7031.5,Business ond p-Trap -
P�ofessions Code�: Gos 5ysrem . . . . ri�Ka`sO�L —,
� I,as owner of ihe property,will do�he plumbing ond Anii-Syphon
�. elenricol work.I,or my employees wiih wages os iheir
sole compensation,o�o licensed coNmctor will do oll MfCHANICAI .
- other work and�he srructore is nol intended or oHered ' O '
. � for sole(Section 7044 BSP Code). � � Swimming Pool Heo�er ��� G S 9 A
� CONSTRUCTION LENDING AGENCY � .. '
, 1 he�e6y affirm that ihere is a construction lending a9ency ior APMICANT -� iE�, � �-- ��e • • o`►�
the performance of the work for which thii permit is issued �pq�NT) Np, '2, � �
.�(Sec.3097,Civ.C.�. I •2 0 Q 5 0
Lender's Name ADDRE55 � �' � � � -'°L 11,Q 5�o
� �lender's Address p.0 Fee f �(O S.J I Permir Fae 0 d-0 �� � a a,t 5—8 7
1 cerii(y Ihat 1 have read�his applicoiion and siaie�hat the . .
obove informatlon is correct 1 ogree�o comply witb atl County ��- � � �iwanca Fee ����S V � � �
ordinances and Stofe lows rela+ing lo b�ilding, electricol, ��„esr unon Fee - � - � -
mechanicol and plom6�ng conttruclion,and here6y aulhori:e. 9 . . . . -- 6 Q `�O ' .
represematives oF ihis County to eNcr upon the above• Toro1 Fee , . . . .
ment�oned property for inspection purposes. . . . , . , . . .
�^�
S�gn �e of nppl�ca�i o�age�� Doie � ��� SEE REVERSE FOR E%PLANATORY LANGUAGE
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