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 '
. N p"'�w� ��� O O V� �n ' a 4 � s. �.L.�.-� O � �- . . � '
dss m a'� cL'c �v S N� � � � _ ° � �6"'.c o m - �' v+ '
„�s„w °� a �o m u°i m s i-3�o s Y B`�0 3 � m �,� 0 3 m 1 �
o�t o � �o �o. + + 0 3 os-o ,� c � �� � � ',
" � �' �o� ��a,-o..� °.. cn �. . o-s N�� ', d .N y o E �°. N a � 1 � � i
��' �-°�a �,� ma pcu� m o 3��',� vro m � oo �v � k � 11 �.
m c ai c� c • _{ .
° � o ai �.°^ a � � £ °- ;�o T,-cs a v o�'� ° �'�°-° ai �^ ,� r p o . � � t ' " �
V.N � � D D E m o o �-c `c=ro Q o � ¢ o a� aa�u 3 ai °c' � ' i I'
Z v ° � o� R-Q, c o '" 0 3 a� t a o � m o o �.,.o �, y a o � 3 �� �
�s, a fl.� - c� ���y .- d _�r O °' v o a .. -c -' ro O an ;
o ?E � t m m E. o y� � � m A�,-o fl- o..o o �, c � ' ',i '1 1
� ° m:s, =� � �y� ��Q-E a4 0 o C .°c m� E �, m � ,°�c.� > U � � 1' '� `�
a U� O- ' t
4"" � °i o'� c a a- o � o c v U o 3 n c o -� "o-o �, o ° L -"-, � 1 �
^' Q �y,*L o a� o a o E � . o.Q a� n �� n� o, o a� -a n ,- N x , 9 t�
w E � a� ` on.�v �,yKo 0 o a� �"° Qa c £ Qc c� m c"c3E �- �v ' ' ' � E
p.� 3v y- � > a� � 4 � o �' �n ° ° m c-n � rn�� � J „ o � ' ' a
a� � oo a � a� o � �c u c � y � s �arc � 0,. 7 0 � � p
�'.' �V �, '" � a m w m ° a ° m a o 3 a' �g a� N s m � �, d n ' � �
� o °V ? o � N.� o � ��• = o �� a � o Ns j �D �'.�o v� Qo Q N �
. ��.as.� ° � n�''�o"+��joNsa�nNNs � �o�a�1����, �j� � � � p� `�� .
�.1 t. O O'� �^_Q.!�'�O O d y3 �' y�nq O 6 U v+ p >Oi y N 'O d �p N O ai � ' ' . .
Z7 � a`. m � am.momoa4 � m-oQ � > �ia7 � _ 1 �
7 � �Z7 A D D�L"O��TS 4 O i N'N C .Q-p � Q T-Q Q . � � .
. O 0� -❑ �n.?i L cyt
O D ao +-L ° utVy•n o '3' n� � D � .�
- T-' � N L{�.�r� a {J� � `c,a p � 3 L m"� � .
� d d �' dj 6�1..S..C u b Q.� u� '
. �j N C �� - N O d w . .
. . �v m� O�a£V� . - ,
•J
� ,.
d
�+ -
�
. .W ._ . _ � - I .
J1 � . .�� � , �
Z � �' � #�.'�
j ,
t "S
R
� ' �
` � '
o � � � �
a d
a � � � � ,�
� -
� �- �-� �
�
� �s 7
� � \� � ' � � � '
x '�+ n - -�' � 'ri c�� " 'a.
j � Q as.�+ `� .�, 2 u `�� w �
� �- ,- � u' �q�,}� � �m° � j° ,�r,t ¢-
. 6 � �. 'j-`i' � � � w �"�° � -��D�
� � .� ' � � � � � i . � i � . a��Na a lr
. 'Z " -g � y� q , 7'� y � .
� g .. 1 � � � �� � ��' � � u. _
w ' s,� _ --
d 1 � 4� � .°��j ��� � � � �'� � _�-----
a � O p � � �a' ' � +�,° � . �- `.-
p � ?. � _ 2 Z d w _ �
r � A ��
--
6'� � a � _. _.
� N J � . —_
t _�..�_..._...-
� ---
. - --'
o _- _
� � , ., _ '