HomeMy WebLinkAbout1095A 1262A (5) � WORKERS'COMPENSATION DECLARATION •ry y
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� �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 -
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