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HomeMy WebLinkAbout1356A 1598A (7) WORKERS'COMPENSATION DECIARATION � � i hereby a�,,,m rh�i � �,��e�� �z��f�n,e of��o�=e�r,o se�f . ._. APPLICATION- FOR-COMBINATION SWIMM-ING POOL PER �BT � ins�re,oc a�..certifimte_ot Warkers'Compehsofion-In3uronce.' � �errifiedmpythere f.(Sec.3B l01 Cl . . . -`ini,2aE .... . . .. . . . . . . . . . ,�f� CEB�h(:"fin) Pol cy No �� C po ��"!�`"= COUNTY OF LOS ANGELES B�ILDING ANQ SRFETY � Ce t f ed py is hereby f nished � � � FOR APPUCANT TO FILL lN - auuoiNc � �{ertified copy�s f�led w�th the munty bu�ld��g i speo -�"�� �- � � ADDRE55 r �`� - � tion,depariment. � . .,r� � '�-�gI Bl11LDING'� � � , y� ,y�.mr.r�,/') .. /.GJ,Jgy��,q,a '�-�. AO�RESS CfVCTC�$ ' IOCALITY � . - Date Applicant�� �vtlYr�w �%�� f NEAREST � � � CERTIFlCATE OF EXEMPTION FROM WORKE '� ��TY � � ZIP ���- �d CR055 ST. � � � � COMPENSATION`INSUR,4NCE.'�� � - SiZE OI` /J ASSESSOR ��� ' .TRAC .lOT LOT NL1. 7/ MAP BOOK . PAGE PARCfL �(This tection n�ed not-be CompleTed�if-}tie���mif is fvr oqs y�� - USE ZONE MAP - hundred dollars'(SI00)or IessJ '� - OWNe 71'"j��.�p �-��'� "'� : NO. - � I-cer�ify�ihat 7n th�performance�of��he wark for which this ,� � SPK!AL � � � . permit is issued,I shall no�employ ony persan 1n any manner ADDRESS - CUNDITIONS -so os to bec6me su6ject to-ihe Workers`�Campensation Laws. ��- y,}�y/.�ry, -/-y DISTRICT STATISTICAL C�ASS iVPE PROCESSED BY � ��T� ' ` Z�P � �` CLA55 NO. CONST. Drfe A plicanf- � � ARCHITECT � TEL. ,�✓ NOT7CE TO APPLICANT Plf, ofter makiny ihis Certificate of ENGWEER � �0.���„'7 �� �� �i Exemption, yov shoUld 6ecome subjeet to the Workers qDDFE55 /b{� �. VAWATION � - �CompensaFo�provisianr o{�rhe Lobor Code,.you��mus�forlh- /�� � VALIDA710N wi�h.comply w.ifh.such provisions or fhis-permii.sholl be- � � -�-�- �� NO. w � S .^��. �3�! �', . . deemed revoked. .. � . � �aNTRACTOR � � LICENSED CONTRACTORS DECLARATION � »e� ��(�/y LIC.1 �cq^� ADDRE55���'u�0 C��yI/Yry� � O.( +��/ I he eby a`firm ihat I am I tensed under provuions of Chapter 9� ��� � f - � , . . ( mne cing with Section 7000)of Di✓son 3 of the.Business ��TY d ��- � � CLA55� � ' ; � . n� � and ProfPssinns Code,a d my license is in full fo ce nd ef(ectJ pESCRIP710N OF\�tiORK �`� 3 7,6�y �✓�,�.yp ,pg���.7 . . FINAL ,/ /. License Number�g Lic:Clas(�a- SWIMMING VOOl ��l%`=�.� � � DATE ���j�f'i�� , �$<-e.e.�2.1� � 7 {1 '� �6`�#{.l� - Qate � cPA �i -�� FINAL ' rs�L�J`� U Confrador SQ.FT. �j,A' , . . �y f' ,i ��-1 am�exempf under Sec � SIZE� � s� Cl�. er , -,��(�41 Q � B.&P.C.for thic reoson ELEGTRICAC � � �-:,��{ `,�}„��_.���,t`, . Q�,j �-�•�5 � .Dote: � d�C . . yyy � - � Steel&Conduit 8onding � - � � - � ��i�� . �" Slgnat�re -- Conduits,Conductors,Equipmnnt� - ��� - � z . - SINGLE FAMILY � � � � . � - . � HOME OWNER-BUILDER DECLARATION PLUM6ING - � I hereby affirm thal I am�xemp+from ihe Conirodor's Licens�� . ..- . . ���,�9�� Law forike'following raoson�(Setton 703L5�. Busittess anr�' P-Trop � 'S Prafessions Code)� - . . Gas System � ��� � - � ❑ I,as owner of the property,will do ihe plumbing and An�i-Syphon ° � 1 j �;�,�j{� eleclri<al�.aork.l,or.my employees�with wages as thei• sole compensatian�or o licensed coNrocfor will do dil MECHANICAL � k,� � ��•� ��j ' other work and ihe sirucrure is not intended ar offered � . � � � � for sale(Sectlon 7044 68P Code). Swimming Pool Heoter - �, �� ����Q JO � CONSTRUCTION LENDING AGENCY � � - � i� �_ %(�� (7u I hereby nff rm Ihot there is a Consirocfion lending ogency for qppLICAN�F�"'�� 7EL.��r -q�r - � the perfermance.of the worL for which�this_permit is issued (pRINP(Q� �� � NO�/��+j � � r' (Sec.3097,Civ.C:). , , - � � � r'�� � �J � a�.. Lender's-Name� ADDRES����t �� - � - 4ender's Address � � p.C.peC S �� �� Pern��i Fee � /���� . I certify ihat I have read tnis application and stote lhat the . ��---�y . . above tnform�tion is wrrect I agree to comply with nll Couniy � issuonce Fee I d "J �� � ,�ordinancr.s nnd State laws relating to building, electriml, . . echonical and plumbing construcuon,and hereby outnorize� Invasrgnann Fec . �y re.pre Pntotives of ihis Counry �o enter upon the above-. � Total Fee �[d� � � menfionad property for inspec�ion purpose5, � � � . ,� . - � � Signawre of npprca„r or ngen� � , _ ��Daie SEE REYFHSE FOR E%PLANATORY LANGUAGE � 1 I 11 1 ,' � ' 1 ' . e p� i 't , � _ l 1� ,.� �.�1 T p, � '� `{ � . m b m � N 6 m n� �.�- ���t d � �� ��f � � �� �� _Y� s 1 o I 1 �1 ' N b O �' O =Q p � � v, � 1 l. � � . � ' . . 'O Q ..- �1 '� v �-a• � 11 , 'O '> G 'Q G� N � y N � C y a 9 �'I , I ' . 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