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
� �
. N � � n.--�- — O 61 m I^ p O
m A
- 4� m m m. � y � o � � �
�o ro G� ,x.,o y I � .y.a n .�� � � ;o � '' c 2 Q � ' a Z �
L � O Y a � G� i""" m '°• a m 1' � Z A % (
�5 �a
f � o Z � m i � �,-, m `� a� i i�Te � c � � i , �o`
A m " -ni f ro rr Z ^° � ` I
� N on �' ' 2 r„ "� � G l O � .m
y -s .b.a n Gl e-is v m
r
m O nU� m - � ��� �
Z z� G� � � p
� �� N
� � ' (� %�� v °` o
C� �
'b:r� ` �� � '�" m -�a
� ��r� � �
c'
_,�ye.,' O. 3 D
i p l9
,_,�. .. � � � -i
�""' �
� � X+ r ,:..,, .
� , {� Ca.r � T.
.,,� �..y ��.� • (% !.- , N
'` �` �1, _' � D
, �
b
"� O� o
,,` �
fl.
� _
� _
.. , - ,
w
- �
m
O
- . m
�p+
� . O
� .. �
,�" .
�
I N �J� �� � o"- m o 3�.� co `°' n's
( v v K �'�n 3-3 Q c� �n °?W� � 2 :- '. m ic�. � N���
.f. � l� S C j.� @ O �.C C Q � Q ��. � 3 N� � �S n 3 Q S tn Q y �.N.,,�
� o fl ° ^ o :�'^ -T� a'' m m � a °-�o C ° � ^ �- '^ -
� m ° o� c � oc° U� � °� � �-� � � � ° QN°� Qmo�,�-oo-aQf..�. �J
� � o � m ,> � ," o °„ '' � �--• � � m s N o n,� ,� o o m-a K m �
o flm °-� �' s° u,� 3 m 4 � � o �N `° ° �K•'< m ' o `n =��, �. o °'3 Z
n
I. c� � � O ❑ � n � N o� C :0 � O� O O O N V cp-L7 0. � O = � 3 � p' N �T� �?
x - S � ;D � . � �+ -' � 7 ,��_, ry � =k s.C �D �' � � . (D - � .
`° � - � Z m ' m 'o °-� 3 n °, ° " m m � m � o o Q C
-�p_ m � o � `" c o o� ,q � 3 Q Q o � 3 7- '� '� � � °-o� � � N o 3 p .
Z � � � � Q _. -�° � ' o--o m � -« m � �� ' n a a m
� -�a O ' "v o � � �o s. m m J ° � o n�D t� v � o � W n �- . � n.f x �o
^' � � ?_ s° v� mj n.� 3 �� o� � oQ -°c o. � ? 3.�n�nro � � `° � � p
� m v, ° n m � o °-b . n:�ro m � Q� �� . c� -a D� 3.-° � � o °D t4� iml
O c�o . � ^ ro ro m o v.% o m ° � c°u o -� � :� 3 � � 3-'� � Q � - � � � -+�D
� 'o` o ,c �, �, m;f m o� s tD ° 3 m w� r, na''o :v
Z �o o ° o�_.= �-�.c m o o c o n°-f ° A U o `°-'�^��°'^ 3'< °�� �
-• a -..Q �_ =3 sc �
,�v � �
fl ��° �O n,;- ci a� �ro .�m � ° o..� Q tr° ° w 3� Q o o � ',R ;�
^9 m o o � �i" o m - a o m � ,� o '� �, o � s <n-
w � � Q'_". m . a � p`� Q Q 3 -«N 3 0 3 w. <". n � o m (?.
� , `" o� � c X � F ° 3" � 0`�.4 � ` �? � '`° ro Q� � °
� -� I w Q� m y� � v _.na o Q � s-o o m � a 2 � m a `� K y �
s - �-o _in£� 3' `s 3 a.-3 Q
Q° -ro � o,m s � o _.� a-'" n o m �m v, m �v v� o o g � n
.. '� in �i"II h� (�D � � s O �,� �. n V�`^ 2� .^. m� < � O- u`i �N O
n Q Q o �v� o m � m �a a o Q � �T� o " `� �-m`� m:�-�.� �
-« -•v o n _ -« o -' > > _ � ',; ,
° -'- -«`� 4 io' ° s�-� �,3 0 0 � +,' n- s 0. ____----
. s p 0,G � n � �D � � ... .. .. ...� .. ._.... . .. .. --