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
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