HomeMy WebLinkAbout0767A 0768A 3
WORKERS COM�ENSATION DECLARATION �
j � he�ehy aff��m �ha' � ha�e o`�'t'"`a'��``°�se�"°Se�` APPLICATI�N F4R C9M�INATION SWIMMING POOI PERMIT �
� insure,or a certiflmte of Workers'Compensotfon insurance,
p or�'certif;r.d cnpy thereof(Sec 3$00,La6.C.) �yFzOp �:
� 7((�-�� ' ����e1 cEa�e i3�aa�
Q�y r�o�La�`L—�Company COUivi'r uF i'v5 ANa,cie5 8UIL6iivi,ANu SJ�FET7
CertiFied copy is hereby furnished.
� POR APPLICANT TO FILL IN gui!owc
Certified copy is filed with ihe"'an.nty 6ui�ding inspeo- ADDRESS
fion deparlment. �.�:; eUIIDING r
#; ADDRE55 � D - LOCAtITY ,
Dote�...-�7"'�y'qpplican �� �--... �j r� NEAREST ' ��.
CERTIFICATE OF EXEMPTION PROM WORKERS' � ��T� Z�P 0 / CRO55 57. -pLa.
COMPENSATION WSURANCE �/ . Size OF n55E550e
TRACi'7 �OT 10T NO. MAP BOOK PAGF PARCEL
___ -.-._......__.._.__ _.._........
(This section need not be wmplHed ff the permit is for one 7E�. USE ZONE PhAP
� hvndred dollars(5100)or less.� OwNea NO. NO. .I'�� _�3�
I certify ihat in the performance of ihe work for which this SPECIAL
� permii is issued,I shall not employ any person in any manner ADDRfS CONDITIONS
so as to became subie<i to the Workers'Compensafion Lpws. DISTRICT STATISTICAL CLASS TYPE PROCESSEU BV
CITY Z�P GONST.r�
Da+e ApplicaN ARCHI7ECT 7et q � CLASS No. �� �/
NOTICE TO APPLICANT: It, af}ar making this Certifimte ot EraG!NEEe No�p "
Exempt�on, you shvuld become subiect to ihe Workers' VnwnTION
Compensption prpvisions o4 ihe Labor Code,you-must forih- AD02E55 -
with comply wrrh such provisions or this permit sholl be TEL /y� S �� �.�
VAtIDATION
� deemed revoked. CONTRAC�U4 NO� "�/,f J ��/(�f •
� �ICENSED CONTRACTORS�ECLARATION ���
I hereb offirm ihpi l qm licensed under ADDRFSS � NO.� q�
g y pro�iisions of Chapter 9 ��� S
� (commenc ng w'ih Sedion 7000)of Division 3 of ihe Business ��T CLA55
� �nd P fess�ons Code,a•�d v y license-s in full force and effeU. �
-�ESCRIPTION OF WORK FINAL - !^' �
��R'�–__ ��� �'�,��`� �
3 .icense Nu�i'� Lic.Class SWIMMINGPOOI OATE�,j�.'�-� �w, 9 l 1 y:
r �
� Cnnirn � � . '•--� D�fe ��'��-�'� SPA — FINA . C�.
❑ SQ-FT. eV � a /1 j ���, � �
I am exempt under Sec SIZE �_ � -
B.BP.C.for ihis reason �Q��� _"� s(d j �.'"`' �
ELECTRICAI ,��``� ��4+.y,: � if�� F1 �!7'� �
' '_'_..� Dafe: " � � (yj
-� Slqnnture S�eel&Conduit Bonding e _. _� /(.-i�� �
Conduits,Conductors,Equipment �
� SINGtE�AMILY Y�� a:� o
HOME QWNER-BUILDER DECLARATION PLUM$ING �
I hereby affirm that i am exempt{rom ihe Contre dor's ticense i a l r r`iJ' �
� Low for ilie following reason(Sedion 7031 5, Business and B . � �� .
Pro(essions Code): P-T��P r�U`�
� Gas$ystem . - - ..
❑ I,os owner of the properly,will do fhe plumbing ond Anii-Syphon
€ eledrical work.I.or my einployees with wages as iheir �- � �
� sole compensafon,or a licensed contrador will do all MECHANICAt �
other work and the structure is not intended or offered
for sale(Section 7044 B&P Code). � L' �%�j; "�`]
� Swimming Pool Healer � .
CONSTRUCTION LENDWG AGENCY
� I hereby affirm tho!ihere is�consiruction lending agency for qppLICAN7 TEL. . . . - - � _
the performance of the work for which this permit�s issued (pRINT) NO. �
(Sec.3097,Civ.C.).
� Lender's Name AD�RESS ,. �
Lender's Address p.C.Fee$ �...-�- Permit Fee/ ����-
I certify that I have read this application�nd stote thpt the . .
� abcve f t��n s m e 1.I agree to comply wdh all Coonty � r��� ��
rdina ces and St te lo �ela�nq ta bu'Id ng, elecirical, Issoa ice Pee /
m ch �I d pl b� y co isiruchun.ond hereby authorize Investigaiion Fee .�
epresen+�'iv,es of fh s Cou ty to enter upon the above- Toial Fee '��
��merit nned�`op�e��,rty for mspechon purposes. .
��'�,�----,. `�–��:_�`7
—___�
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