HomeMy WebLinkAbout1232A 1375A WORKERS'COMPENSATION DECLARATION . � �
I here6y aff�m ��a�� h �e o�e��,f,�afe of�o�5e�?,o=e�f . .. -APPtfCATfON FfJR�-COM�BINATION--SWfMMING POOL PERtV�IT
�nsure,or a-ceriificate�of Workecs'.�Compensation Insuran<e, �
or a cerrified copy thereof(Sec.3809.La6 C.)} � ��a2oo� � - � - � �
,,,�s� a,, ��s � .� GCNIF.(3/84)
Pol cy No.SL�g Company "�""�'"�'� . . . .COUNTY OF LOS ANGELES . BUlLRING AND S.4FEFV .
-- � Ceriified copy is hereSy furnished ': � . .
FOR APPLICANT TO FILL W Buaortv�
� � C lified opy is filed wifh ih munly bu"d'r� - - ADDRE55 ',�j
� f depolmeN. - -�iSl�I , � .BUILDING �j�+? � .
� ADDRE55 J�-/ �OC/+uTY � .
- Date Applicanl��.� . . . - � NEAREST -_-� ,
� CITY ZIP CROSS ST.
CERTIFICATE OFEXEAAP710N FROM�WORKERS'- SIZE OF ASSESSOR .
- COMPENSATION WSIJRANCE-- -� � TRAC� LOT LOT NO. - MAP BOOK PAGE�� PARCEL
(This.secfion need aot�6e compleTed if The permiT 1&far ona •y,� TEL USe ZONE MAv
.6undrsd dollars(j100)�orless.)� � -� � � OwnIER /•ti.-G�.'� NO. ���NO�. �
I c� hfythnt in�the perfarmance of the work for which this SPECIaL � � �
' per ii is issued,I sh�ll�not employ�any persorr-in any manner ADDRE55 CONDiTIO1JS �
' so as Itl becorrie s�bject to fhz Workers'�Cbmpensotion Laws. - �DISTRICT STATISTICAL CLA55 tYPE PROCESSED BY�
. . - . . . � CITV ZIP � �CONST. °.
Date � �Applimnt � - � ' ARCHITECT O TE��a 1 CLA$S NO.
�NOTICE TO APPLICANL.If, after making ihis Certificale of - ENGiNEER �� �^.'7�-" NO{p��l"�.a1-q 4��� . '" � .
E ert pfion, you shoultl-�become subject to �he�-Workers' qDDRESS,���.R7.G-{�.�i�. - VALUATION /} � � �
. Compensation provisions of the Lobor Code,you musf forih- � � /'p � - Vp11DflTION
w th comply w th such provisions or ihis-permit shall be - TE�� � � �
deemed revoked � CONTRACTOR� �0�"� �N� ��� ��� �
� LICENSED CONTRACTORS DECLARATION . - - ._ . LIC. - �
, I hereby affirm fhot I�om licensed under provisions of Chirpter 9 ADORESS N�. "�J"1.�� , � _ _
LIC �S� - t �':�%.�
(<ommencing ��h 5ection 7000)of Division 3 of ihe Br;s�ness �� ,y�� - - �,f�', � �p�g ., -.
and Professio Code,and my license is in full force pnd effect� . - . �� �o � � !j . �
(� DESCRIPTION OF WORK' FNAL ��/__ . �
license Nu �r5��� Lia Class "�� SWIMMING POOL DATE � � 1 �.4��;:7-- � �
� Coniracior ^� .Date- � J SPA �FINAL (( - LL�',j %�; O .
❑ . .. — SO.FT. /�y� . . BY {,�{'� .� ..
I am exempt under5ec. - 51� `"' " " � (�O� p� � �
B.&P.C.for�his reason � . - ELECTRICAL. . . � '�,����_��_��,, �- '�V� ��� �� '�.
� Date: � � - �.
�Si noture �� Steel&Conduif 6onding - � � d-
9 Canduifs,ConducYors,-Eqoipmenf � .
SINGLE FAMILY � � � � � � � � � � - � �
HOME OWNER-BUILDER DECIARATION �PLUMBING � � - � � �.� -
I hereby affirm thai l am exempf from ihe Controcfor's License - - , . - . _ .-
Law for the following reason(SeUion 7031.5,Business and p_Trqp � � � � � � � � �
Professions Code)� - ' - - . Gos 5ystem � - � � � - � -�- � - � - � - � � . � �
� I,�ps owner of the property,will do the plumbing and P,qti-Syphon � . .. .
eledr eal work.I,or my employees wiih wages as their - � �
sole compensafion,or a licensed conimctor will do all MECHANICAL ��� �'��J�
olher work and the structyre is not intended or offered . � � � � � � .
for sale(Section 7044 B&F Code). Swimming Pool Heafer �:-� � ��y I.
� CONSTRUCTION LENDING AGENCV � � � - � , - . . ;��o � (�j,-(j(� '�.
� I here6y affam thot there fs a mnskuciian lend ng agency for � qpp�ICANT � 7EL � - �- �
the performance of ihe w9fk for wh chlhis permit is issued (pRIN7) � NO. � ' I f`J.(��u
� (Sec 3097,Cro.C.). � � - � � '�.
Lender's Name ADORE55 � � - �' � . U 1 ; 6�`�`5 i
Lender's Address p.G Fee$ �'�� Permrt Fee /'��'-S.� � . ��
I cert fy that I have read Ih s appl mtion and state�hat the - • . / ` ,.1 , � . �
a6ove mformat on is mrrect I agree fo r,omply wrth a�l County . Issuance Fee � ` �'`3~�° . - - - �
ord nances and Siafe laws r�la1 ng 10 building electnml, . � -
mechaniml and�plumbing construction,and�hereby authorize �mesrigmion Fee . �/� �„l_�,_ - � ,
represenmtives of this unry to en�er upon the obove- � Toral Fee 'P . .
menti-. d properiy 4 r n �ti i urpQses. r,.l- . . . � � � _. � - � . - . .
..... � s �������� � � '
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