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HomeMy WebLinkAbout1742A 1823A �. WORKER$'COMPENSRTION DECLARATION , - I he�eby aHirm that I have a cenificole of mnsent to self insure,or a tertifimte of Workeri Compensation��=�,a��a, APPLICATION �OR COMBINATION SWIMMING PQOL PERMIT ; or a cenified copy�hereof(Sec.3800,Lab.C.) 76A40B ., . . . � `., . n.� �J�� p � CE-875(11/81) Policy No. 5�3-Company�(/� 7/'�-UY'+"� COUNTY OF LOS ANGELES � I BUILDING AND SAPETY . � Certified copy is hereby fumished. - � � FOR APPLICANT TO FILL IN BUILDING � Certified copy is filed wilh the county building inspec- ADDRE55 fs�j lion department. /�/� BIIiLDiNG �-�-y � Date�~�� APPIiCaN .1Cd/��"�✓ AODRE55 I��U , �� N�ESTY CERTIFICATE OF EXEMPTION FROM WORKERS' CIN � ZIP CROSS 5T. G SCJ// - . SIZE OF ASSESSOR COMPENSATION INSURANCE TRACT.Z.S�9�r LOT l0T NO. ..lG� . Mqp gOpK PAGE PARCEL (Thls�ecllon nNd ne1 b�complNsd if the permif fs for one iEt.y USE ZONE MHP �` /���/s . . 1lundred dollar�(SIOO)or I�ss.) OWNER f. NO.p G�� V �� NO. a r- I certify�hof in the performance of rhe work for which this �i SPECinL permit is issved,I sholl not employ any person in any manner ADDRESS � !�� CONDIT�ONS so os to 6ecome s�bject�o rhe Workers'Compensation LawS. - � p15TRICT• STATIST,�AI C1A55 , TYPE PRpC�SSED BY CITY ZIP CONST. / � � Dale Applitanl /RfHITEQ � / TEL CLASSNO. NOTICE TO APPLICANT: I(, after moking ihis Cerlificate of ENGWFER GC.C�.l(iyaq/ No.G3Uo�y � �� �j� �E-�-�-`'�" . Exemp�ion, you sho�ld become s�bjett �o the Workers' � v�tUAnON Compensation provisions of ihe labor Code,you�TVSf TOrih- ADDRESS S VAIIDATION � wifh comply with such provisions or ihis peimil shall be TE�• J�33 S �I�OQ^QO deemed revoked. ' CONiRACTOR �NO LICENSED CONTRACTORS DECLARATION v� ���' � ADD4E5 f—+ i kD.�S`U'�.5� %'� I G.2 A I hereby offirm�hof I om licensed vnder provisions of Chopter 9 S .... . . ... . . ecommencin wiih$ec�ion 7p00 of Division 3 of the 8usiness ���' R 5 �e . . .�, � nd Professions Code,and my license is in full force and effed. C�� � �"L'�� f�nSS 3 _ ,,, �Q�'� DESCRIP110N OF WORK 1�1���XX-77��,, FINAL � License Num r�s��� lic.Closs=�3_ SWIMMING POOL � � DAtf � • •4 1.6 5 V � ^l ([ ► � Contradorv `�Date�'��"7��/� S�A . . PINA '� • 0 4 1,6 5� � Osct.cT. 2Q sy u I om e.em pt unde�Sec SRE ,/Q� �2 G 7�8�l N B.BP.C.for Ihis reason ELECTRICAL. � _ _ - . l�7 C ? Dote: � L �,L�G.f� -1JJl.+, Sieel 8 Conduit Bonding + � � Signature Conduits,Conducrors,Equipment ' � � �(C •}(7lSSv"e . , SINGLE FAMILY � � HO".'�E CJ,'tiER-6UILCER GECLARATION � PtUMBING - 'j I�I��'y�,� � ' I hereby affirm thot I om e.empf from�he ConlraUor's License � Law for Ihc following reason(Sedion 70JI.5,Business ond P_T�ap - � � f^(/N2 , . . ' . Professions Code): � L/ .. Gas Sysrem_ _ �1 8 2 3� � I,as owner of ihe properfy,will do the plumbinn nnd Anti-Synhon . � . , electriml work.I,or my employees wilh wages as Iheir , . .. � � . H_�.�.• • •3 , sole compensation,or o licensed cantractor will do all �MECHANICAL � � � other work ond�he s�iocture is not intended ar offered �-�� � - . ' � ,� •� J��Q , for sale(Sedion 7044 B8P Code). Swimming Pool Healer ' "� � � � CONSTRUCTION LENDING AGENCY � � � • ° � F Q J�O c=i � I hereby affirm�hot there is a cons��uction lending ogency for AFPLICANT _�' TEI. � ! .O 3.O� —H A Ihe performonce o(Ihe work for whith Ihis permil is issued �pR��,�{� NO. , � (Set.3097,Civ.C.). _ . ' lender 5 Name ADDRESS � � lender's Address P.0 Fee S �� G'� Permir Fee �• `y - n I certify that I have read this applico�ion and s�ate iha��he . � � above information is correct.I agree to comply wi�h oll Counfy � �C/ � . � _ '' � o�dinontes ond SIo1e lows reloling to building, elecfricol, IssuonceFee mechanical and plvmbing conshvc�ion,and hereby auihorize ���Pst�goiion Fee . representatives of Ihis Covnly lo enler upon �he above- 7otolFee /�!� u�0 / memioned property for inspection pu�poses. - �� ,��rc �*�.� ..z-�7-� , . . .. . / S�gnalure of Applican�or Agenf ooie SEE REVERSF FOR E%PLANATORY LANGUAGE \ O � � - . r-� � �o v S n T m ,� �n � � n m � y Z -+ � 70 O ^ D Z C �1� "� Z � = ` > D O O (1 m �� . . -. O � � D �r � � � C1 (�\ N m A H A � r- O ' "�� p :� - I � � 2 70 � � v' � � �.� � 1 � � 0 1 � m � . . _ fl T " ' =i .� O T . �, FS 3• -Ni D A z � m m y � Z / • m C � m � � . (1 � 61 '^'^ ` �^ < ` � O ti � �, Dn r c ° �. O o. 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