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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 � - �- �- - - _ ' � --�� r., �es m�� � cw S `1 [1 �-- m � -•�— ` ~ _._� 'O '0 ,� ',�� O � A ! ~a C �'� .5.�' � r � . I � -�i c�i� �Z� g �g m O . �O O � Z � O -a ` �' n � ^e p t7 -� �- 'C p � ' m. S N � '1 .� � � �Z C � n A0. - Hr^ �` I°' � . �� �++ r � "° -� � z O. z N z u'' O �° � m m S r�ra . � � �.0 �� m I , � � .� (9 � 'fl st 'i an < � .� �A Q ml � �� D � a I � �� m � � a� i z � �� 1 r 7- �.., � �. 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