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HomeMy WebLinkAbout1356A 1598A WORKERS'COMPENSATION DECLARATION � � i hereby a�,,,m rh�i � �-�,�e�� �z�if�n,e of��o�se�r io se�f . ._. AP�PLICATION-.FOR-COMBINATION SWIMM-ING POOL PER �BT � ins�re,oc a�..certificpte_ot Warkers'Compehsofion-li�3uronce.- - �ertified�opythere f.(Sec.3B la! Cl . . . -`rnA2G6 .... . . .. . . . . . . . . . ,��j-rj ,�f� CEB�fi(�,un) Po1 cy Nosd1_��-� po ��"!�`"= COUNTY OF LOS ANGELES B�ILDING ANS?SRFETY � Ce t f ed py is hereby f nished � � � FOR APPUCANT TO FILL IN - auuoiNc ��� � �{ertified copv�s f��ed with ihe c�unty bu�ld��g�.nspeo -�"�� , �� � � ADDRE55 r � � tion,depariment. ���-�_ Bl11LDING'� ,�� � , �.� ,y�.mr.r�,/') AO�RESS CN�=C�-d"' IOCALITY � Date Applicant_ � . f NEAREST � � � CERTIFlCATE OF EXEMPTION FROM WORKE ` � ��TY � � - ZIP �r�- �J CR055 ST. - - � � � � COMPENSATION`INSURANCE.^�� SiZE OI` .!'J ASSESSOR ��� ' .TRAC .lOT LOT NL1. 7/ MAP BOOK . PAGE PARCfL �(This iecfion n�ed not-bQ CompleTed�if-Ihe pefmif is fvr otta y��, - USE ZONE MAP - hundred dollars'(SI00)or less.) `� - OWNE 71'"j:J�.'Sp �-�� '"� : NO. - � I cerufy�i4�ut th�performance�of��he werk for which th�s ,� SPK'�AL � � � . permit is issued,I shall no�employ ony p_rsan 1n any manner ADDRESS � - CONDITIONS so os to bec6me su6jecl to-ihe Worke s{ampPnsation Laws. ���- �/'� /'ry DISTRICT STATISTICAL C�ASS 7VPE PROCESSED BY � . . . .. CITV � / .�'TT'� ZIP ( ( � QA55 NO. CONST. Drt2 Applicanf- � � -� ARCHI7EC7 ��-- � � TEL. ,�✓ NOT7CE TO APPLICANT: If, ofter making ihis Certifica�e of� ENGWEER ,/(j"�` ��0.� �„'7 � '� �i Exemption, yov shoUld 6ecome subja<t to the Workers qDDFESS /6 y� �. VAWATION � - �CompensaFo provislanr o{�rhe Lobor Code,.you��mus�forih- � VALIDA710N with.comply w.ith.such provisions or this-permit.sholl be- � � -�-�� �� � Np a" � 3 :2� �.�! �', . . deemed revoked. .. � . � �DNTRACTOR � � LICENSED CONTRACTORS DECLARATION � �''�p ;q1� IIC.1 �cq ADDRESSL�4j��u�0 C��'�� O.( ��� I he eby a`f rm that I am I tensed under provuions of Chapter 4� ��� � f � , . . ( ne cing with Section 700U)of Di✓son 3 of the.Business� ��rY d nj� � � CLA55� � ' ; � . � � and ProfPss ons Code,o d mv license is in ful I fo ce and ef(e�tJ pESCRIP710N OF��tiORK '�� 3 7,6'�t �✓�,��pe ,pp���.7 . . FINAL ,/ /. License Number�g Lic:Clas(�a- SWIMMING VOOl ��l%`±�.� � � DATE �����f'i�� , �$«-�g.e.@?.1� y: 7 {1 '1 ��`��y° {•l� - Qate � cPA �i -�� FINAL ' rs���J`� U Confrador S�.FT. r"j,A' , . . ��f' ,i SIZE� \7 �1�. ey • ;��J c.� � ��-1 am�exempf under Sec � \ �' �' o� � B.&P.C.for thic reoson ELEGTRICAC � � �� ` �,�}„���`,L`, . Q�,j �-.•�,rj � .Dote: � —..SC . . yyy � � Steel&Conduit 8onding � - � � - � ��i�� . �" Slgnat�re -- Conduits,Conductors,Equipmnnt� - ��� - � z . - SINGLE FAMILY � � � � � . � - . � HOME OWNER-BUILDER�ECLARATION PLUM6ING 9 - � f hereby offirm thal I am exempt from ihe Controctvr's Licens�� . ..- . - ��s'�!`�.��C�y Yll^—'-v. Law forike'following raoson�(Setton 703L5�, Busittess anr�' P-Trop � �������,�.. Pr�fessions Code)�- - . . Gas System � ��� �� - ❑ I,as owner of the property, vill do ihe plumbing and An�i-Syphon ° � 1 j �;y,g{� e.le<Iri<al.aork.l,or.my emplcyees�with wages as thei+ sole compen�atian�or o licensed coNror.for will do dil MECHANICAL � k,�m � ��•� ��j ' other work and ihe sirucrure is not intended ar offered � . � - � � for sale(Sectlon 7044 68P Code). Swimmin8 Pool Heoter - �, �� ����Q JO � CONSTRUCTIOn�LENDING AGENCY � � � - � � %���:'i(j� I hereby aff rm Ihot there is a consirucfion lending ogency for qppLICAl4F�"'�� 7EL.��r - � the performance.nf the worL for which�this_permit is issued (pgi,N7�f� ��, . ryp�/����' � � r (Sec.3097,Civ.C:). , , - � � � r'��� � �J ^ A�.. Lender's-Name� ADDRES����t �� - � - 4ender's Address � � p.G Fee S ����� Perm�i Fee � /�LF�� . I certify ihat I have read tnis application and stote lhat the . t ��---�y . _ above tn(orm�tion is wrrecC I agree to<omply with al4 Couniy � issuonce Fee !�d "'� �� � ,�ordinancr.s nnd State laws relating to building, electriml, . mer,honical nnd plumbing construc��on,and hereby outnorize� Invasrgnann Fec . representotives of ihis C.ounry �o enter upon the above-. - TotalFee ��� � � menfionad property for inspec�ion purpose5, � � � . ,� . - � � � Signawre of npprca„r or ngen� � , _ ��Daie SEE REYFHSE FOR E%PLANATORY LANGUAGE " �n-=_c �r d �'-a ' � c ._v �� w �� m c� �� c �6 � Q,o y ' I � ' ' u .�s . m � �a:'.. �� C `oo o�� o � � R f ( � ( I I o :s ; 0 3" m aa 3 ° � m-� �. � o �,� � o I f i , I I i � �ch � o o..c � o c y �` v , c�t_"_' � a�o ,,, `c o u +� II �; i ! ! � i O O y �n O �i N i � �n V D 9.. p y, � 1 I II . , ,+ . , . - � � � �a� s c a�v,..�S � o � '"-0 � u�i �4.s aa � N l3 a� ,U ' II � I.. I . 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