HomeMy WebLinkAbout1021A 1022A � WORKERS'COMPENSATfON DECLARATION �
4 .
=='�r ���,� � nvve q cert�iicate ot consent i self qppL�CATION FOR C�MBINA-TION:SWIdNMING POOI PERI�IT P`� G� �
� ;,z z:,y�
'� insure,or a cert�fmte of Workers'Compensafion I s ance, �� �7�
G or a cerhf ed copy thereof(Sec 3800,La6 C) _ � -�hqz�� . ,
� . GEb�fi(3/84) -
Policy No. _Compa�y C6UNTY OF L05 ANGELES BUILDING AND SAPETY
� � Certified copy is hereby furnished. � � . `
BUILDiNG
� �Certified copy is filed wµth the counry building inspec- FOR APPLICANT TO FILL IN nooRe55 �F''J��' " --;�� ��g��,
tion deportmeni. . BUItDING ,� �j i
� � � '� � ADDRFSS `'-(�- 1��, � �"L, i,� LOCALIT`! � � r ' - '" .
- Date ��� Applicani � NEAREST k ,E � d� ,
� CERTIFICATE OF EXEMPiION FRO WORKERS' n CIiY �J'� ZIP CRO55 ST. .
� y �'j SIZE OF J `� � ASSESSOR
CQMPENSATION INSURANCE -. TRACT,_,,,,-:�. t+� j LOT LOT NO. J MAP f300K . PAGE PARCEI
(This secfion need not be mmplefed i6}he permif is for one 7FL 7 .. tISF ZONE MAP �-'� y
hundred dollars(5100)or less.) �. OWNER j � . NO r` -,} No. A `, ._�e' ....-�s�. � ..
I ceriify thai in the performonce of the work for which ihis �I�,`�, SPECIAL
permit is issued,I shall not employ any person in any manner ADDRE55 `-CL,J� ��[�, L CONDITIONS
. so as fo become subject to fhe Workers'Compensation Laws. - - � � OISTRICT STATISTICAL C�AS$ TYPE PROCESSED BY
CRv (�}"{,J(l�J�' ZIP --� � CON57 �
� Do±e Applicani ARCHiTECT O$--- TEL EY,1 CLASS NO. �/�
� NOTICE TO APPLICANT: If, affer making ihis Certifitate o4 ENGINEER p. � � _3 z,"_',t �(i'' .F�- - _
g Exemot or, you should become suhjert in the �Na�kers' i �YALUATION ~ � �
Compens�f on provisions af the Labor Code,you-must forih- ADDRESS L} ��
� wlh cnmply w�h such provisions or ih's permit shall be TEL�C .e � J +`\ ���(� VALI9AAC3N
n deemed revoked. CONTRACTOR �#L.�(,�.� ',� NO.c, '- �—� "
LICENSED CONTRACTORS DECIARATION LIC.- ..
I hereby aHirm`hat i am licens=d under provisions of Chapler 9 ADDRES � �,NO. � �)'� -
(commencing with Secfion 7000J of Divisinn 3 of ihe Bosiness ���,V�, f-"' ���- �` 3 -� , � �
and Professions Code,and my license is in full force und effecL C�TY ��t� f1A55 ._ �, ;,�, , ,. .
'�9 Q�� Q DESCRIPTION OF WORK .F�NA� y��^ �� r g �t ? �'
I.icense Number�l�.�_'C� Lic.C�ass_���� SWIMMINGPOOL � �DATE �l��ci � .__ � .
Contr�dor� `�0 Date�����_� SPA � � �FINAL � . � � � p� �
❑ - 54-FT
I nm e.empi under Ser -SIZE `:�BY ��� k v'.y� v ��
0.8P.C.for th s rencon � - � � �'"; �:,�" ' O ,�
� EIEQRICAI � -
Date:
�'�1 � � r;�r. � I
Steel&Conduit 8onding ��� �j �.^'� � p.,�
Signoture ._ ,�
Conduiis,Condvciors,Equlpment � � f � }�° r fn �
SINGLE FAMILY � ��j�{/�Jj .. r �; i�
HOME OWN[R-BUILDER DECLARATION PIUMBING fJe�e- ��r .' ' �
3 I hereby affirm'hat I am..empt f�om the Contracior's L�cense -� � .
999� Law for ihe following eason(Sed on 7037.5,Business and �,S.
� Professions Code) P-Trop� � _ - � - *� f
Gas Sys�em
❑ I,as owner of the property,w�ll do the plumbing ond Antr$yphon . � �� � �j�a �
� eledricol work.I,or my employees wiih woges as iheir� . _ .. _ - �_ -
snle compensation,or a licensed contractor will do all MfCHANICAL
orher work and the struciure is not intended or offered �� r
� for sale(Section 7044 B&P Code). $wimming Pool Heofer �/ `� ~v-' ���' � �F��f'?. �
� CONSTRUCT!ON LENDING AGENCY . _ -
I hereby pff�rm that ihere is a censirudion lending ogency for APPtICANT 7EL �
ithe performance of the work for which�this permit is issued (PRINT) NQ � , ,
� (Sac.3047,Crv.C.J. ���. _ .
i Lender i Name ADDRE55 . � ..
�
� Lender's Address r� / u- �(> _ � �
P.C.Fee$ -/�� � . Permit Fee /�.J E �-
! I certify thot I hove read this opplication ond state�hat the - : .
�� above� fn at�on is corretr.I agree to comply with all Couniy Issuance Pee / f� �S� �
� ordino ces and Stote Iaws relating to boilding, eiectncal, � � � �
� mecha mi nnd plurnb ng construc�ion,and hereby auihorize ����esr ga�ion Fee � ,
representotives of ih s Counly lo enter upon the above- To�ol Fee ; 3 (�
tlone properly For�nspection purposes. - - . � �
j t t��t�y�J:�; � . . . � . �.
� Sgna; e of Applicom or Aqenr Gma S�@ REVERSE�OR EXPLANATORV IANGUAGE � - �- �- - -
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