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0873A 0957A
�� ,.. - WORKERS'COMPENSATION DECIARATION ��� � ' � � ��-�' � ' ' � -�"�4! 1 here6y affirm �ha�I have a ceri"rficafe oF consent io self APPLICATION� FOR COMBINATION� SWIMMING POOL PERMIT - ins�re,or o certifica�e of Workeri Compensotion Insuranco, � . . or a ceriified copy�hereof�Sec.3800,Lab. .) �6a.aoe .. . .. . . � . . . .... . .. . . . .. . -. _ . .�. . . _ . �. � CE8761�/8�1 �� voticy No�7s�� Compony COUNTY O,F LOS ANGELES BUILDING AND SAFETY � � Ceriified copy is hereby fumished. ' - - - � - �� � '� � - � - � ' D FOR APPLICANT TO FILL IN . suuoiNc _ _ . Certified copy is filed with the county building inspeo � ADDRE55 3G7 7 , ��on deporfineM.. . . BUILDMG , . , , A�DRE55 � IOCAUTY �� Dote Applitanl � NEAREST � � CERTIFICATE OP EXEMPTION FROM WORKERS'. � ' ��TY � Z�P CROSS ST. w!\ � �� COMPENSATION INSURANCE - ^ - SRE OF . i C ASSESSOR , _ TRACi e� lOT LOT NO. / a MAPBOOK PAGE 7ARCEL (Tbis s�cHon n�od eot bs complN�d if th�pvmit�k for on� TEL �!'/ USE ZONE . MAP hundr�d dollars(5100)or INf.J . . . OWNER�. NO. I�/�(r �1 . NO. � - ��� - - . I certify iha�in ihe performance of rha work for which ih�s . 57ECIn� . � permil is issued,I shall nof employ any person in any manner ADDRESS Q CONDIilONS so as ro become subjeu to the Workera Compensation Laws. � , � -� � �I tRICT SiATISTiCAt CIASS- TYPE . PROCESSE�BY � ' c�n zia coNsr. �ale Applicont ARCHITECT OR d' : . 7E�, ,I O QA55 NO.�1 ^� � � NOTICE TO APPUCANT: If, after making this Ceriificate of ENGINEER �•�/ nl �>� . E,empr�on, yo��.shoold become subieU ro rhe Workers' AooRess Ot'7-�A' -Iy VAIUATION- � ��- � Compensotion provisions of tho Labor Code,,you�mus�forih- � '�""'�'�'�'� �>/ , wUh comply with such provisions or tbis,permit shall be TEL. - f �-Q �- . VALIDATION deemed revoked. - - - � � CONtenCro �� No. ��Q � UCENSED CONTRACTORS DECLARATION ��� � - 7 ���• � - � - �� � � I hereby offirm thot I om licensed under provisions of Chopter 9 AnDRE55� Ncb39'��'U s � . � , �commencing wiih Section 7000�of Division 3 0(the Business. 'n LIC. CIT ✓-�C fX}� QA55 C S 3 and Professions Code,ond my license is in full force ond effect. . . r 0.8 Z 3 A � ❑ESCRIPTION OF WORK FINAI - � '�l� �� �'• •.2� License Nu er � Lit,Closs �`r'3 SwIMMING POOL O � DATEi4�-�� `�-�- -� � ' � y: � _ � a � CoNmcto �Dale . . .. SPA . .. . .. FINAC"� . . . . I •.•4 5 3 7� � p SOEFT. 3 er ��`�f�^ . . .4 5.3 7� v � I am exempt under Sec.� � - � 1 �("� � � . . . L� .. B.BP.C.for Ihis.eoson . . .� EIECiRICAL . . ... . .._ . . . �y.['� „_ 1�/\` ��2.Q-$5� U Date: � \S'�l`l�v 1�� � W � 9 Steel&Conduit Bonding - B r1 �O"/ � .� . . . n-� Si noNre Conduils,Condudors,Equipment d`• 0 b � z , SING�E FAMILY _ _ HOME OWNER-6UILDER DECLARATION PLUMBING � ' - �-� - ' I hereby offirm ihof I om exempt from the Contracror's License ' - � � Law for ihe following reason�Section 7031.5,Business and P i�aP - � � � � � � -� (���- � � . - � Proiessions Code):� - "�� � ' Gae System �. .- .'� \I. �Q 9 ra 7 A � I,os owner of the property,will do the p�umbing and. Anti-Syphon � � � � Q-�_f �.� � ��'� - - , �� electrical work.I,or my employees wiih wages os their .. ._ __.. .. ._. _ . �.• • • ..•3 . �. sole compensation,or a licensed confractor will do oll MECHANICAL - - � � � �� � � � � � other work and�he siroclure is not inlended or offered� . _- . . -. __,. -_,. � ., . . . '.• .� b�O Q for sale($ection 7044 88P Code). ' � � -� Swimming Pool Heater � � Q� � � - CONSTRUCTION IENDING AGENCY � � - " � � �-��� �]�J.O O c=i I hereby affirm Ihot there is a construction lending ogency for qpRICANT TEI. • the performance of the work for which ihis permit is issued (pg�NT) N� �� ��� � � � � Q(x z 5-8 5 (Sec.3697.Civ.C.). . . . . ., . . . _ .. ...... . .. ... . .� .. � . lender's Name AD�RESS - �- �- �-� � � - � _. . . . .._ _.. . ._. . .. . Lender'S Address p.C.Fae S S Permif Fae �����'�� �- - � - � �� � - � � � i certi(y thot I hove reod ihis application and stale thot Ihe� � above informotion is correct.I ogree lo comply with all County � � � �sa�anca Fea IU'�U � ordinances and Stote lows reloting to building, eleciriml, mechanical and plumbing constroction,ond hereby aufhorize.. �n�esngar�on Fee ��. �� �-� � . . . �� representotives of this County ro enter upon the above- Toiol Fee � . mentione roperry for inspeUion purposes. � • . � � �� - -- � �� . �'�U� ._ . .. . . . ., - S� �o ure o Ap imnl or AgeN Da+e - SEE REVERSE FOR EXPLANATORY LANGUAGE -� �� ,. _ . . .. ,__. ._._ . . .__ _. .. - - � avai�a _. - . ` - ._' �. ,�,'Z ,1' aovNivaaiooa " , _ �. � , . . . , , , . .... _ .. . _._. .'�_ _; i` . .. �, . , � .. .. / 1S313Nt15tlD � ,_ � - , ! � , _ ,. � ' � (1N3A 8 NOIltl�01)N31V3N . ;- . .. . . . . . � . _ .� .. - �IM1�313 lVNif � - 9NIeIM H9008 . . . � , ... .��. . . . i . . . , . . .. . . ..� ' - �- � � � �� � 5310N 5,801�3dSNl � ' � ,_ ' �a I ONIH71tll'd7351 531vo l `JNISOD-i135( �aump ol00 � � . . . 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' ._' ,_ �-w�qnns �oy� papinad 'sae6o�dwa umo s�y y6no�y{. - ��o gasw�y��om�y�ns saop oyni puo�uoa�ayysano�dw�� . - �\, ' � _ � � �waNOe �o�sppnqoy.v..(�iedo�d�o�aumouoo�,S�ddotousaop.�no7 . •- � .esua��7 s�opoquo�eyl:epo�suoissa�o�d pua sseu�sng ' , .- �- - ,, - . �� �-� � - . , � t.�" , �� 11f1aNO�1HOl1 (qyp�•�as)s�os�oy pe�ago�o papua�ui�ou si e�nyon�ys ay1 ' �� ' puo•�ioM ey�op�pm•uoi�osuodwm e�os�iay�so:a8om � � - - �� - , - - � - ' � � ' swaoi 8 73715 y�iw�see6o�dwe Aw�o'A1�adoid ay�}o�au,v�o so'�� � � � , . . . � � . . .:('(OOSS)s�opop. - _. . . __ . ... .,. � _�. . . - Nottv�o7 �' pe�puny on�;uoy�e�ow�ou�o A��ouad pnp n o{�uo� ,, _ _ •qddo oy�sa�e�qns�iwiad o�of�uwqddo,(uc.(q S'I EOL '- . , - ., ' . J 801�3dSN1'- .31tl� � NOI1�3dSNl - , uoll�ag �o uo�lvlo�n duy •uopdwaxa�pa6a��o ey7��o� � . . . -'�:,",'•...•.� . . . s�soq ey�puc wo��a�ayF�dwaxa s�oy�oy��o(epo)suo�s � � . � � � � :��!�, �� , � .-salo�d puc sseursng oy��o�uols�n�p�o(OOOL�°lPaS � � � y�im 6upuawwoa)(6�a�dcy�)mo7 esuan�7 s�opol�uo� . � - , " � ' � � ay��o suo�s�no�d oy�o�tuons�nd pasua�ll s�ey joy+�uaw � - � -e�oJs pau6�s o a�i�o7llw�ad yans�o�iva���ddc eyl sailnb . �. � •_��� • � �• � . � - • � .. • --o�os�o.'awonssi stl ol.�oud.'a�ns�n�is 6uo�loda��o . .. . '• '. - ._ . .__ '_ . �' .. � • •qs�jowap�eno�dw�va��o•��n��suo�oi pw�ad n se��nbe� � � � � � , �� � �-e�op`, ': •oN �, oyop � . •aN 4�14m:tluno»o6�rnduy:opo,�suoisso�o�dpuassautmg . . . ._ ... . . _ ` .. .. ._. __. ._. .. - ��ea�ddy .. . � ... . _._ . (S'tEOL �'�aS!��uosoai 6uiMo��o��oy+;�o};-moj,esueoi�1' .� �_ �� . . . - ' . � : s�opoi�uo�ay�woi}Idwexa wo�joy�wii;jo-Xqaiay � �� psuin{ea � :ol . � NOIlVatl1�30 213411f19'N3NM0 . .. , � nl�� � 1NV�nd�v Ol SNtlld �_!. . .. ., _ , . . . .