HomeMy WebLinkAbout1742A 1823A (10) �.
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 \
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