HomeMy WebLinkAbout1094A 1266A (5) , WORKERS'COMPEN54TION DECLARATION � ���� � � �
I hereby af(irm�hat I have a certificate of consent to self
insore,or a certificate of Workers'Compenwiion Insurance,' APPLICATION FOR�t..�MBINATION SWIMMING POOL PERMIT �
or a cerliiied copy thereof(Sec.3 ,Lab.C.) 76A40B��� - - � ' � � -� � �
r "� CE076(3/B�) \,
Policy No.��Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Ceriified copy ls hereby furnished. � � � �
�( FOR APPLICANT TO FILL IN.- euaoiNc
V•I Cerlified copy is filed with t county huilding inspec- ADDRE55 - .
�`—' tion deparimenl./'z�/ � BUILDING
; Dole�Applicanl ADDRESS I NE�AAREST �
� � CERiIFICATE OF EXEMPTION FROM WORKERS' � CITY 21P CRO55 ST. �\ �`'LC`(\
COMPENSAiION INSURANCE SiZE OF ASSESSOR
TRACT� LOT lOT NO. MAP BOOK PAGE PARCEI
(Thla saction naod no1 bo complN�d ii tha parmit it for ono TEL. USE 20NE MnP
hundrad dollan(5100)or Iess.J � . OwnIER NO. . NO. �� �
I cerlify thai in ihe performance of�he work for which ihis SPECIAi _ . .
permit is issued,I sholl not employ any person in any manner ADDRE55 CONDITIONS
so as lo become subject to the Workers'Campensafion laws. - - �-- - - -- � --� �� -- DISTRICf STATISTICAL CLA55 TYDE PROCESSED 6Y
' CITY ZIP CONST.
Date Applicanl ARCHIiECT OR TE� �^\ C1P.55 NO.
NO110E TO APPLICANT: IF, after makin�this Cerfificafe of ENGWEER v 3 �
Eaemp�ion, yoo should become subject lo the Workers' � - � VAWATION � '
Compensoiion provisions of the lobor Code,you must forih- AooReSS �
�wiih comply wi�h such provisions or this permit shoil be _ TEL. s YALIDATION
deemed revoked. GONTRACTOR � NO ,
IICENSED CONTRACTORS DECIARATION ��C. ' � ' ' '
ADDRE55 � NO. �� ���� . .
I hereby offirm that I am licensed under provisions of Chapler 9 ��� �S \ � � , .
(comme�cing wilh SeUion 7000�o(Division 3 af the Business CITY CLASS / � '
ond Prolessions Code,and my license is in full force and ef4ect. �uRIPTION OF WORK �
FINAL ►
License Number Lit.Class�� SWIMMING GOOt � phTE� � ' " ):
SFA. . . � � '• � � � � n-.
_ '_.._.. .. . .
CoNractor �a1e � FINA O
❑ SQ FT. . . 0 . .
I om exempt under Sec. � d S12E �� �g•�'A �
8.8P.C.far Ihis reason� ELECTRICAL . . . . . . � . �t• • • a'�� �
Date: .. ._ . � • .7�.�:� �
Signalure Steel 8 Cond�il Bonding � � e . . � .
Conduits,ConduUors,Equipment N
SINGIE FAMILY • ' I�,Ll O ci Z
, HOME OWNER-BUILDER DECLARATION PLUMBING , ���- � - -- � O B.2 Q—8 S
' I hereby affirm ihat 1 am eaempl trom Ihe CoNracbr's License �
law ipr�e following reason(Seciion 7031.5,Business and PT�aP . � - -' - - � � , ,
ProfessionD,Code): - � Gas Sysiem _ . . . � '
� I,as owner of�he property,will do ihe plumbing and AnliSyphon . , ,
+ eleUriml work.I,or my employees with woges os Ihair . . . ... . _ _._ ._. . . ._ _ .
sole compensation,ar a licensed wMractor will do all MECHANICAL - � - � '
other work and the struUure is not in�ended or offered • .. . . �� G�6 F�
' � -far sale(Secfion 7044 88P CodeJ. ' Swimming Pool Heater -- - " � • Q� - , ' . ,
CONSTRUCTION LENDING AGENCY -- ' --� - ' -- '�' F��:�����. •3� �
` I hereby olfirm Ihot there is a mnstruction lend��g oge�cy for APp���N tE� � ,
the performance of Ihe work for which this permil is issued (pRINT) NO � � � �2 F�.5�
(Sec.3097,Civ.C.)." �
�� u
� Lender's Name A�DRE55 � �2 5�� U T
Lender's Address ��'3� —�8
P.C.Fee E O Permi�Fea � �•� ' � ,
I cerfrfy ihot I have reod ihis appliwtion and slale thal Ihe � .. . �
obove information is mrrect.I agree b comply wilh oll County � . . - � . /d �'j� -- � - - .
ordinonces and Sia�e laws relaiing to building, electrical, issua�<e Fee , , ,
mechoniml ond plumbing canstruclian,and hereby aulhorize Investigaiion Fee � f T,S �
represemotives of this Counly to enter upon ihe above- � To�o1 Fee V !/ � , � �
d r peny ic inspection purposes.
K 7�k-�'�
�wre f Applimm ar Ageni Daie . � SEE REVERSE FOR EXPLANATORY IANGUAGE
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