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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 �������� � � ' , --`�aamre of .o - nr ���are SEE RFVERSE FOIE EXFIANAi�RY LRNGiIAGE �-�: ; � —� - !` �, ..._ _ _ - - -- - . _- _ z_ .. . .. . _.r . , . _ � � .._ .,:- � -': ..-_� — ____-'. , -_ .-:-` _: �' .-.-� . ...�_ -. �: ,� .c � � c a _So ^ � `oo �= c�� Ay � L N ' ` I � w + � a 9 1 P y 1 � � M- � U V A � C L �I� I , I �CJ U N UI OJ 'G � v' O—Q� ' �' C �n O � ' .,p�' . . 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