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HomeMy WebLinkAbout1615A 2883A � WORKERS'COMPENSATION DECLARATION � � i� �� �� . ,�S�rebo:a`�"`�f��'��of w°ke,s"�om'pensa},o�=��s��a�;<e` pPP�fCA_TIOtV FOR C(���I�iA�IpN SWIMMfN�-POOL PERMIT � or a ce�fified mpy Ihereof(Sec 3800,Lab.C.) �sa2o6 � f �E8Z6(3/84J - - � Poli�y No. cornpa�y COUNTY OF LOS ANGELES BUILDING AND SAFETY ' � � Cenified copy is hereby furnished. - �:Certified co FOR APPLICANT TO fILL IN BUILUWG � .�, py.is filed w ih!he coun�y�-building inspec- ADDkESS E�_ - �- tion departmeni. BUILOING ) /'^� y� � y� - ADORE55 � ��� �.�/IJl.dt�"-l.� (�y�r� /i� LOCALITY ��-+� �p�e Applicanl NEAREST �� CERTIFICATE OF EXEMPTION FROM WORKERS' CITY �,c.�...,.,;...: �.a.rC. ZIP CR0555i. =(}�C.GpZi.J' T/fL�,(J l v COMPENSATION WSURANCE SIZE OF n y� ASSESSOR � TRACi ���� LOT LOT NO. �C.aLJ MAP BOOK PAGE � PARCEL (This section need not 6a completed if ihe permit Is Ior one r� iEL USE NE MAP , �z-+ hundred dollors(5100)ar less.) OWNER jt, jJe�.��$ NO.:Y(ol" Z 2L �� . NO. � !(�.5�'� `� I ceriify thol in the performance of the work for which ihis �) � (�� } SPECIAL � pe�mit is issued.I sholl not employ any person in ony monner 4DDRE55 ;��� / �h+t�l��i✓� C'Y2,e�- �i� �T"'" CONDI714YN5 so as ta bemme su6jed to ihe Workers'Compensati ows. ^t, ' �/ DISTRICT SiAT15�A�CLA55 TYPE PROCESSED BY '~� J CITY V 7[:tM e�„�e.� ,L)F-> ZIP CONST. ' Da���Applicd � � ARCHITEGTO � 7EL CU+SSNO. �! NOTICE TO APPLICANT: If, afrer making this C i icote of ENGWeea �.(., 1`��r+�M$ NO. <�,(,L"�Z.� � �� / Exemption, you should become subject to the Workers' � q �+ VAlUA710N � � - Compensation provisions of the Labor Code,you must forth- A�DRE55 �O�Z,,. GiG:Ct 1`.l.t.� C�l�'�f�✓ � -` with comply wiih w<h provisions or ihis permil sholl be 7E�. f ,r ��y� - YAUDA710N deemed revoked. CONTkACTOR '�- qi..�. �c.p( �No. �d�fJ � �`�' �/"� LICENSED CONTRAQORS DECLARATION . yy� ��C. � = � I here6y offirm ihai I am licensed under provisions of Chapter 9 ADDNeSS Q %..�,��..a�;�,�cs,i [t+�NO.�LS 7Z,3 - ��. � � • / uC. f �" (commencin9 with Sec+ion 7000)of Divis on 3 of ihe Business �ITY /�-h+o-1,¢�M ClASS�.��1' and Professions Code,and my Lcense s in full for�e and effect. 7h� ' 7 DESCRIPTION OF WORK (I�/ I F1NAt� �f� License Number y�C-�.��3 Lia Closs�'��� SWIMMING POOL � - DAT r ,-- (� `/,� �/ ► �. ConirocloT-^�5����• ,�'r�S Daie _�7/�6 SAA FINAt '- � ❑ so.Fr U 1 am exempf under Sec 51ZE � BY 9 F � �. , �1.. A o B&P.C.tor rhis reasan . � --:- , �_ .. . U � ELERRICAL . ��-- - Dnte: -� - ��$� /�,�� - ,{t, ,� e e c L� W Steel&Condwt 8onding �'C` v t �� ; �,.'�.S � � SignaNre Conduits,Condudors,Equipment � . � � SINGLE FAMILY -- HOME OWNER-BUILDER DECLARA710N . PLUMBING — - ��� . = °'-' r ��-4�*-' r- 1 herPby affirm thm I c m exempi{rom Ihe Conlracior's-License '. ,_ fi`4, s`w`sr.�'.� ��� � Law for Ihe following repson(Sedion 7031.5, Business and P_7ra � ..�,�:�i� ��i�J � Professions Code): p ��_ .. GasSystem _ ..,,yyg��'� �#'YT.� � I,as owner of the property,will do fie piumbing and Anti-Syphon - �a = ��, � electrical work.I,or my employees wrth wages os iheir -- :i� � � - �: '==�� `` . ' ' - .._ . r __ .s Ie compensofon,or o licensed coniractor wiH do alt =MECNAN�CAL�- - - : ' INh wark ond ihe structure's no1�ntended or offered ' ..i� ; for sale(Sec�ion 7044 B&P Code). ; Swimming Pool Heater ._ .__�,__. __ .. ..�`. .-. _ _.. - . � coNsrRucnoN iENoirvc acervcr ' - _ - �P��3 R I hzreby aff-rm fhat 7here is a conslrudion lend�ng agency for �- - �=- '�"i`�u . � - ihe erfarmance of ihr.work for wh�ch th�s - APPlICAN7 . P Pcrmlt�s Issued �7 �../ tEL .-;► ' _. �"$..e s d � r 3 (PRINT) �.(LEy�� /�[ NO. .�t3°-fG'� (Sec.3097 C v.C.1. . - . te��de;s rvome nooRess z.�Id /1.�C.f a.�J c.re...�'' o� ! �3�0 5 t3 z AN.:. � Lender's Address { - . �°j� '`�'��� � P.C.Fee$ C) �J3 Permit Fee � '� � I ceri�fy ihat I hqve read th s applimilon and staie thor fhe � - - . ;� ��'�,+��.(�' - � abave informatinn is cortect.I agree to comply wilh all County �,�� . - � � -- � ordinonces and State �aws relot ny to bwld�ng electrical, Issoonce Pee - � rnechon cal and plumbing construd�on,ond�nereby authorize invest gatw„Fce ���(�p ��� �� -— _ . � . es of 4�is Counly to en�er upcn the above- to�al fee � menfioned p ap or� �on purposes. � � � � �� � �-. � �� - �S�gna're of apPl;mni or .nr yDate - SEE REVERSE FOR EXPLANATORY LANGUAGF -.., . � a - -n � D �n � 61 A � r' �. ? p O. � � u�i H Z C -Di Z n ? .� D v�i 2 Z S ''-' D p D A m � O -.i m '- fi� y m A v� A � C n �p -_I � � m A � = T n v m -i G=1 O p z 2 D " A � � 2 Z Z ,a N . ~ � -r �o T m � a o m G 3 m � 1 D � � TT � N � ~ N � 0 ry�j O D� v � . 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