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HomeMy WebLinkAbout1095A 1262A (5) � WORKERS'COMPENSATION DECLARATION •ry y �a � �u�� �- ��' , � � � - �``""V`��' `V""r' ;°"'` APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � �� �insure,�or�a�ceriifimte of Workers'Compensation Insurance, or a certif'F- copy thereof(Sec 3800,Lob.C.) 76q�pg (�..� ��}L�(�•-!.1'� !�„� � CE-875(11/81j . �.rlicy No`f 1"t YV l Company :7Ya ,�,Q�._ CQUNTY OF LQ$�►NGELES BUILDING AND:SAFETY � Certified wpy is hereby fumished. � FOR APPLICANT TO FILL IN auaoiN� � �Certified mpy is filed wiSh iF�e c;ounty building inspec- ADDRESS r Iion department. �.� �' ---...-��---� "'�� � j' BUIL�MG , � { �. � � ADDR[S$ C� LOCALITY i Date `� Applican , NEAREST �''"'�� ' ,_ „ � CITY ZIP . CRO55 ST. . J;��`"k„+ti�'�� �� ��j�.\„`5 C'� . CERTIPICATE OF EXEMPTION FROM WORKERS' � ------- � COMPENSATION INSURANCE SIZE OF ASSESSOR TRACT � g �� LOT LOT NO. �; /SqP BOOK PAGE PARCEL .(This se[tion need not be completed if ihe permi4 is for one TEL USE ZONE MAP �--y � - hundred dollaes(5100)or less.) OWNER NO. - NO. , }, �``�� !. -..__._. I certiiy that in fhe performance ot the work fpr which�his SPECIAL permit is issued,I shall nof emp�oy ony per5on in any mpnne� ADDRESS CONDITIONS so as to become s�bject fo ihe Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSE�8Y CITY Z�P CLASS NO. CONST. � ' Dqfe Applicant � ARCHITEC7 OR TEL. �� �� � � "��'-. NO?ICE TO APPLICANi: IF, afier making this-Certificote of ENGINEER NO. C";- �_ � Exemption, you should become subiect to the Workers' VpWAiION � ' � Compensaiion provisions of the Labor Cade,you�musi forth- ADDRE55 �. with comply with such provisions or this permit shalf be TEL. S VAt1DAT10N deemed revoked. CONTRAQOR � .NO. 2 LICENSED CONTRAf_?ORS DECLARA?ION qDDRE55� NO. I hereby affirm that I am licensed under provisions of Chapier 4 , S � (commencing with Section 7W0)of Division 3 of the Business CI7Y = � /��,, C A55,� +'� ond Professions Code,and my license is in(ull force and effect. '�Y-�" �'', _ g- j� �'� DESCRIPTION OF WOF'K � � � FINAL! � ► CZ License NVmbers�.�,�.�r�Lic.Class�,l�, SWIMMING POOL . pATEL'�2 � � Contracfor��� Date ' .�_� SPA FINAL � - _ � 3 ��=�'� � ❑ . .,- r.. SQ.FT. �. . . , 5j I�rn exernpl u�der Sec._ �o .,'�� SIZE_._._. � _ BY �'g � � `: + �y � 8.8P.C.for this reason � !-. � � . -- ELECTRICAL . �,..,,, t�_��{�'�1 ('�� .. � n p ��, r � Date: `,��4°+.'A.��,�+�`�'s Signo?ure Sleel&Conduit Bonding "�� a �n " 7 45 Conduits,Conductors,Equipment � � SINGLE fAMILY �..���,s�. � n k�/z'.-_.Fj� . HOME OWNER-BUILUER DECLARATION PLUMBING � i hAreby offirm thaf i am er.empl{rom the Contracror's Licanse Law for ihe fallowing rPoson (Section 7031.5, Business and P Trap . J � Professions Code): .Gns System ,i-3 � � �- . � - . -_`,�' ❑ I,as owner of the properfy,will do ihe plumbing qnd Anti-Syphon �j � _ � ' eledrical work.I,or my employees with wnges os iheir . . � sole compensation,or d litensed contracror will do all MECHANICAL � � - - � other work and the siructure is noi lntended or offered � for sale($ection 7044 B&P Code). . Swimming Pool Heater _ . . . CONSTRUCTION LENDING AGFNCV �- �� G`''=��� I hereby affirm ihat ihere is a consiructi�n lending agency for- AAPLICANT � � TfL. � ii� @ � 'a y�;? � tha performance of?he work for v�hich ihis permii is issued �pR�N1� NO. - _ . (Sec 3097,Civ.C.). a�� ,�,�rl Lender's Name ADDftESS� � f . . . � u�Gvl�'..`.�c' tender's Address P,C Fee$ ,'�„�(_ �� Permir Fae ���.�� I ceriify ihnt I hove reod this application ond stafe ihat ihe ` U�"� ���' above information is<orred.I ogree to comply wiih all County Issuance Fee �� ""1� � ordinances and S�a�e I�ws relating to building, clectriml, �� , mechonical ond plumbiny consirodion,ond here6y authorize �n�Asngation Fee _ - - representotives af this Counfy to enter upon �he above-� Total Fee '°6.,,L�'},:) % =��' - � meNio prope�y. r inspection purpose---��'r�`-I--'Ls— . �q^�..,.e ot�aal��o.,.��n.ye:�. ,. �� 3�€�€V€n3€�3R fX�[Ai:n�vRY iFi:vutive - __ —. ___,. _ _ - ----- ------ -� � � ; :� -� � �, � �; � __ � _ � ._�� .��—�— �� �- � � -� � �T� � �, � � � � A � ..___ � � � � � � � � g � � � ��r� �• � n � C9 . . vi � � sn � 7 R = �'e � -^B � _ �u G 73 r�. 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