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HomeMy WebLinkAbout1470A (8) WORKERS'COMPENSATION DECIARATION ' �' - - -� Q � I Aereby affirm that I have a�e.r�f��o�e of�,�se�f�o�sB�f - APPLICATION FOR COMBINATION S��I����Rll���� insure,or a certificate of Workers'Compensation Insvrance, ^ or a c r fied� rher f c.3800,Lab.C.). '' zo-omeovwve�� ' � ' � " � ' ���-� �� Po Co pany 76� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS � Certified copy is hareby furnished. . � � . � ' �/� BUIL�ING• �' � _ ��� ��f(�ertified copy is filed wit un� building inspeo- ,, FOR APPLICANT TO FILL IN nooeE55 7�tfon deporimeM. � BUILDING Q AODRE55 � C� IOCAUTY D(� �� ��('—s Dota�Applicant � clrv^,��p �^o Z1P . . NEqpEsr A � ' CERTIfICAiE OF EXEMPTION FROM WOR RS' ' �, w' r�--� �R�SS 5T. v''Y`� C�LJYa U C COMPENSATION INSURANCE '� � SiZE OF ASSESSOR � TRACT �3�O LOT � LOT NO.S hMP BOOK �- � PAGE� �� PARCEt (Tbi�c�N�on nNd nof M complN�d li Ih�p�rmlf Is ior on• e TEL. USE ZONE MAP � bunJfYd dollaff(5�00�Of I�ss.�_- � OWNER � {„�, NO. _ 1� r NO. ��Z�-{3°J�j - I certify that in the performance of the work for which this ��I� -�f''1 T� bC I SPEdAt � ' permif i3 issued,I shall not employ ony person in ony manner ADDRESS � � 1 �Cr�Q C_...���:.`�W {� IT CON�ITIONS �� � w os to becoma subject to 1ha Workers'Campensalion Laws.� DiSTRICi STATISTICAL C1A55 TYPE PROCESSED BY � .. . . . : CITY �y�.L.p� - 21P ;�' QA55jJjD./.� . CONST. Dale � � Appli[anl ENGINEER �R f'"{��CS N0.�,5��Y7 ��`� 1 � NOTICE TO APPLICANi: If, after making this Certificole�of J� 1I - �\' � ' 1 � � Exemplion, you shOuld become subject to fha Workers' qDDRESS !�JlY �' t Uv�T-+ -NU J VAIUATION Compensation provisions of ihe Labor Coda,you must fonh-� VAUDATION - with comply with such provislons�or thia permit shall'�,be� CONTRnCiOR L�I�) G2�,Zj NO�.et(p� L S r3�ti`.�YS � deemed revoked. � � � , !2 � � � LICENSED CONTRACTORS DECIARATION ' npoaEss �I(D. /�AZUS�' rio. (,� I hereby offirm thot I am licensed under provisions of Chopter 9 p�� ��� /� f �- � ' � � (commencing witb Section 7000)of�ivision3 of the B�sinass� CITY WUl!�l C1A55 (i`� � � �� . � � } ond Profeuions Co and my license is in full force af d effect. pEKRIPTION OF WORK a- ` ( FINAI ► O Licansa Number���i(�1�Lit.Class `��� .. SWIMMING POOL � DATE �� (�'�a n. V � � u . . . . . rt � Commcror� �-G�- � Date � � � SPA FINAL n. .,. .21 O SO.Fi. -6Y- F' ' � I am exempt under See. 5¢E , - ... . . I y .5 6 5 2 w B.BP.C.for this reason �� � ELECTRICAL : . . . ; � (� !: •� .. 2S(i-.'1 . . .n', •v 6 5 2� y �� ..�� � ;Z Date: : ����7�� �Si nature - Steel 8 Conduii Bonding -� � - , ' - ,— 9 ' Conduils,Conducrors,Equipment "- "- � SINGLE FAMILY � � �� . � � • • • •3 � HOME OWNER-BUILDER DECLARATION i . pLUMBING . �� ��f�,���.8� . I hereby affirm thaf I am exempt from the Conimctor s Litensa� � - .. . � ' � � � _ � � Law for tha following reoson(Seclion 7031.5,Business ond ' P T�aP � � . ,.�i.. � . � Professions Code): . - � � � � � - Gas Sysiem ' - � � � I,as owner of Ihe property,will do the plumbinq and. � Anti-Syphon � � . �� � electriml work.I,or my employees with wa9es os their � � � � - - , sole compensotion,or a licensed mntractor wiil do.oll� MECHANICAL � �oiher work and the structure is not inlended or offered for�� . , - �. . � sale(Sechon 7044 B8P Coda). Swimming Pool Heater �. � . , "" � - � CONSTRUGTION LENDING AGENCY � � - � - � . � /�' �� �' -� - � � 1 here6y offirm ihot there is o construuion lending ogency for'. APP���NT TE� � -, � � � , the performanca of ihe work for which this permit is issued� �PRi � ND� . ��aSr -� � � � � �� (Sec.3097,Civ. J. �Q//� / . . . Lender's Nome��11_I`-*C� � . . � � ApDRE �L � �}-._ .. ► - . . . � . . Lender's Address - �' � � ' � / f Q'^ '� � � �. P.G.Fea S �p•`� Permn Fea ' 1 V^ - - I certify ihot t tiave read ihis application and sfote thal fha � above informo� n is correct I agree to comply with all Caunty ��� � �- � � ��Cj S� - � " � �� �� ' , -- ordinances qnC;;tate laws ralating to building, eleUricol, Issuanca Fee , � • � mec am rn�pl ing consiruction,and heroby authorize' Investigauon Fee - � � �'1�,.�SO . � � � repr sentotive o ih County to enler opon fhe abova- Torol Fee oS - men ianed pr erty fo inspection purposes..- � '� . , . .. _ - � � � � � - � � •� � . � , I �"I �. _ , � Si nature of Appliwnt or Ag � pote � � SEE REVERSE FOR EXPLANATONY LANGUAGE . . I , . , . .�: ,.• ... ��..,; „- , ,� - - _ . �,�:' , ��,; .� - -— -----_ _-- -_ -- -. __ __ , • � , � � , dnU��� . ; ,. , .,, . _... _ . ._ __.---- ---- - --= � ..� , . � , ` �r,- a�rHiraa iooa _ : . . , �.,�.< ----- ._ - --- - — - . ..:.'.. ... . 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