HomeMy WebLinkAbout1615A 2883A (9) � 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 � . O 0
Z n 0 m Z �
QC =Z
C
Z
� ��
x r
� D
1 ` {`-' t � � N .
iV � � �1 N ��.:..% ,r., D. _ � O
w
J q' � J� t "' � �
� C �
n
v 3 D
n' `- � o. z
,��� � -i
�-..:
� � Z
4 �
� � m
o a
9
, A 9
O
<
�
a
Z
v
m
�
O
�a
�i
2
O
�
4
o -. � - a o-�c sa • wsf a� ., p y v� n3� o � ao � -
o m _r c f o'in o c c m o i� ° H � fl °� w � ° � ° � � .B m m s
, � ° ❑ o v a''' •�� ❑o m o � � ca o o N � � ❑� p i„ �n� ° �-"o N � � �
-�.. �p c N O - N O N vNr N y� n o - p � Q v o fl W�' o
� , � j i" C' �` O O Q � Q
3 � �° °'�.�.To °�v o 3-� H�-o ' m '"� o^ � m�o�m-°o � T' n.f -. 0
n n
� � � `o ° W � °3 m c u F o�' � ' � ' �-o v° a 3-°m -�� = �• o ° � z
i _. � � �' � � . . � �a o 0 0 � m a ° O � � ° -^ 's m
� " �-� ¢,N ' Q `° 0' _'2� <�o _. m � � • � N3noHTo �
i � O �7 S 7 j O N p � � � � O n k S< H
N � � o � m o �o o � 3 � ° o m' o � m �o � r Q o� $ j `° o C
. v p � �n n m 7 n � ��o =� '1 � N � 3 S `� -.� ui O` ° -
m a m o H � a o -r o � n..a m p � � � -o � �^ 0 3
- n � �p � + o -Y � �9 m . N�c F O � W a O k � n"O '+ fl �
� W cn � 'p W Q O Q "O a O � q � O 3 O p 3 O 7 �� � � �? S�� � a� x A
� m �n �� N^ o' o � 0 2• 2� m o a m �-a � a° ° m � � `4 � 3 �
0
m o � �� m '� `m o v �°m� o ..i � � 3 f° 3 �� �' 3 a �D o n
p �o o a o� �o- 3 ' 'o,��m m o � 3 � �m�o ° � H �' '� m � D
�-f --J Q in � ' • C. j .O � C p n d�� . � :: < �C �,O � . `1 O O �7
N � a3 no ° Qa- ��-a o =� � � '_" m _ -� 3 o 3 A
� o oa N 3 0 � -. �y m Y o o.� o Q,o`'o N o v ���? � -1 .
� 3-� � - m N m � ,� m 7 � 0 3 3 o O n o T O
�o Q o � � � 3 F o a� o o fl s 3 -«,n 3 Q '" 3 <_ �. � `m ^i^ `D Z
�° n � -i C 'D ��-�Q �T•'S� � N � < �n' 7 O N m,�!] N • O cp (�
� c � °,m T'" ° � � � `D °a�� o � _ a� . o
C� N �� (l � N cD Q �-4 (1 N � '�� O N C � v� �p -p�Q ur a� 3 � O Or
G
0 j N� ] p n O N 3 N ��d(G p F a a° + p� � �O � �. S w O
A � � � T ti �
. N O � � Q (nDY � f0 (� f0 +3 O O � A Q T a�� � .0 � �' tD N N 7' T(� ,n