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HomeMy WebLinkAbout0861A 1275A (4) /� �.JRKERS'COMPENSATION DECIARATION I � ` � {� �f:reby affirm that 1 hove a cerfificote of consent to self �� ,insure,or a cerlifimte o(Workerx'Compensation Insorance, APPLICATION FOR COMBINATION SWIMMING POOL PERMlT � �� � �or a ce�iihed copy thereoi(Sec.3800,Lab.C.) 7e.420s � - � � - � � � / .sT/3T� Fur�J ces76�a�ea� Policy No.t�`aj���anY COUNTY OF l05 ANGELES BUIIDING AND SAFETV � � Cerlified[opy is hereby furnished. � - . FOR APPLI ANT TO FIIL IN BUIIDING p�j� �Cerlified copy is filed with the couMy b�ilding inspec- Q AODRES$ O M - � . tion deparfine�Ny. � BUttDING ��J Dale r � `��11PPIicant ADDRE55 /�,! f 2 LOGAIITY � � - ' . .. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' ��TM Z�P • CROSS ST. 0 �(,3"' " S ZZ - COMPENSATION INSURANCE SiZE Of 4 ASSESSOR TRACT �. lOT lOT NO. `� M4P BOOK PAGE PARCEL (Thls axHon need not h�comp4t�d 11}he permif i�for on� TEt. � U ZONE MAP ��,! � � . h�ndrad dollars(f100)or la+s.) OwNErt �7} �. �NO. �_�� Np,. Y' �� I certify rhot in ihe performonce of rhe work for which ihis , 7� ��^ ,�� SpE�iq� . _ ., . permit is issued,I sholl no�employ any person ln any manner aD�IiESS � � �. U� �Q Jr .6",�� . [ONoiT�ONS so as to become subject�o�he Workerz'�ompenialion law3. . DISTRICT STATISTICAI QA55 '� •�IYPE PRp�E55ED 8V � CITY f A j�. 21P � �-. : CONST. � ....�, `,�U155 N�. .�/ Date Applicant ARCHrtECT " TEt. O - NOTICE TO APPLICANT: If, ofter moking this Certi(icofe of ENGINEER , /�(� NO.(� Q]�'f� � Exemptian, you should bemme wbject to �he Workeri qDDRE55 ` 'C VAIUATI� � � � . Compensation provisions of�he Lobor Code,you�mus�for�h- +�1•� � VALIOATION wilh comply wilh such provisionz or this permil shall be q TE�� �--� s �Q deemed revoked. (CONTRACT (J(L(.�/�-� O. — � LICENSED CONTRACTORS DECIARATICN qD�RE55 f7'/G� NO.�j7 G S� � I hereby affirm that I am licensed under provisions oi Chopler 9 ��� w�Q �s . , � � � . .. �G 8 6 T A � (commencing with Section 7000)oi Division 3 of the Business •CITV ' and Professions Code,and my license is in full force and efFeft. �� �55 y— .. . �-'.. . . �i• • e e 2� � � 9 ,pry��D^�•l ^3 � �ESCRIPTION pF WORK �fINAL � �f litense Numben)166�D'�L,aic.Class i � (�� � • ^J�6..7'J i SWIMMING POOt x DATE (J��tl / Pooc.s �. a ConlraClor�FA+Tv��Z� Do�e `P�13�' � SPA � FIHAL ' � n e e:G�J c=.', •U ❑ �so.rT.' J� . °Y . 1 am eaempl under Sea SIZE {� ' O�,,`2 C`�i b Q,• B.&P.C.for this�eason � EIECiRICAL [� � � � �` � - � 9 Dale: � Steel 8 Conduit Bonding � � f"_"L. ���, ..' � � ` .. • . . a . Si noture Cond�its,Conduclors,Equipmenl ���ry! � � Z SINGLE FAMILY b V � HOME OWNER-BUILDER DECLARATION p�UMBING '�� � � � - � � - � I here6y offirm that I am ezempt from�he Contractor's License p� � _ ' Low for the following reason(Section 7031.5,Business ond P-Trop r+S �C.'rT� � ►�. ' � Professions Code): � � � � . , � . Gas Syslem _. . . � I,es owner of the property,will do the plumbing ond Ami-Syphon � � - ' electriml work.I,or my employees wi�h wages as their . ... . _ ..... . ,g� '_�F F� . � �sole compenso�ion,or a licensed con�rocfor will do all MECHANICAL . other work and tha strucNre is not intended or offered � - - . . . � �� fi�e e e e a� � , for sale(Sedion 7044 B8P Code�. � Swimming Pool Hea�er � � � " ' ' � � CONSTRUCTION LENDING AGENCY . � . I �O�G O,�O � � �hereby offirm 1ho1 ihere is a conslruclion lending ogency for APftICANT ' ' ' ihe periormance of ihe work.for which this permil is iswed (pg�Nt) ��- � p NQ.�� s � . ° ^[U il��� ` �se�.aoa�,c�.e.�. . 0 i:2 5—8 b lender's Name ADDRESS ���y� �uGA/i p N 3 G} . . . � , tender's Address p,�,Fee S S . Permil Fea ��- �� � I certify that 1 have read this applicoiion and sta�e that the �-7, . above informalion is corrett.I agree lo mmply wilh oll County - � �- Issuanca Fea ��� J V ordinance:and S�ate laws relating to building, electrical, mechanical ond plumbing mnshuction,and hereby authorize �^�esigarlon fee `�f1 � � �� ' represenlo�es f Ihis nfy to enfer upon Ihe above- Torol F�a � V•�7 v ' meMio ert _ection purposes. � - " a�--��3—� , -. . . ; 1 u��e of AppGcan�o�Age�r • Da�e � SEE REVERSE POR EXPLANATORY LANGUAGE � - , � i I , , { . � _ _. - . - ' - � .. .. . J .. . . . • . . _ . . . . . .. 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