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. � - "
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