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HomeMy WebLinkAbout0767A 0768A (4) 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 Ceriified 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 wmpleted ff the permif 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 " Exempiion, you should become subjed to the Workers' VAIUATION 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$ystem . - - .. ❑ I,os owner of the properly,will do fhe plumbing and Anii-Syphon € eledrical work.I.or my einployees with wages as iheir �- � � � sole compensafon,or a licensed contrador will do all MECHANICAt � other work and the structure is not intended or offered for sale(Section 7044 B&P Code). � L' �%�j; "�`] � Swimming Pool Healer � . CONSTRUCTION LENDWG AGENCY � I hereby affirm tho!ihere is�consiruction lending agency for qppLICAN7 TEL. . . . - - � _ the performance of the work for which this permit�s issued (pRINT) NO. � (Sec.3097,Civ.C.). � Lender's Name AD�RESS ,. � Lender's Address p.C.Fee$ �...-�- 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�d pl b� y co isiruchun.ond hereby authorize Investigaiion Fee .� epresen+ s of fh s Cou ty to enter upon the above- Toial Fee '�' ��merit nned�`op�e��,rty for mspechon purposes. . ��'�,�----,. `�–��:_�`7 —___� � � 5i��,�,��,�N�,r a;poi�w�i o�nge�� �o��e � SEE REVE85E FOR EXPLANATORY LANGUAGE � - � 4 � � . 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