HomeMy WebLinkAbout0828A (4) i �� _ . __� -= r_.��w-.._ _ .
�i� WONKERS'COMPENSATION DECLARATION �
� he`ebY af`��m �hor � ha�e a `e�,�`�`°,e of�o°se°��o se�` APPLICATION FOR COMSiNATION SWIMMII�G �POAL PEIRIIAET �
� insure,or a certificate of Workers'Compensation Insurance,
' or p certifi d copy ihereof{Sec.3800,Lab C,)� 7sa2as
�'�C" cea�s c3ien� Suk�DING AND SAFETY
Policy No.�Company�„� COUNTY OF LQS AfdGELES
�' � Cerfified wpy Is hareby fornished. �
'� �Certifiad copy is filed with the coun� buildrn ns ar FOR APPLICANT TO FIL�IN BUILDWG �
Y 9� p ADDRES$
� tion depar�men"`t�. BUILDING
Date��(y_Appli�an�t��.C�„ ADDRESS � LOCALITV
NEAREST
CERTIFICAT�OF EXEMPTION FROM WORKERS' qTY . ZIP , CRO55 ST,
COMPENSA710N INSURANCE f) / SiZEOF /q ASSESSOR � �I
TRACT fJ`�� S� LOT LOT NO. 'L9J MAP BOOK PAGE PARCEL I;
, -(This secflon naed nof be complefed ii Ihe permif ic for one 7EL USE ONE MAP y ,�^a
� hundred dollors(SI00)or less.) � OWNER N0. � � NO. ��L) " �Y'4� I
'�, I certify that in�he performance of ihe work for which this C,.� SPECIAE j�
permit is issued,I shpkl nof employ ony person in pny manner ADDRESS �S�,rn:e/ �Y7�CTf� CONDIFIONS
�, so os to be<ome subjed to the Workers Compensotion Laws.
� . DISTRICT� STATISTICAt CLA55 TYPE PROCESSED BV � i
', CITY � ZIP CONSt. j
I, Date Applicant ARCHITECT OR TBL J� CLA55 NO, �� � �- ;
ENGINEER NO. C�
NOTICE TO APPLICANT� If, after making this Certificate of � �
� Fxemption, you should become subject to the Workers' �
� Compensation provisions of ihe Lobor Code,you must forth-
ADDRESS �ALUATION
with comply with such pro�islons or this permlt shall be TEL. ry VAL�AATION
deemed fBVokeCJ. CONTRACTO .NO, 6 s �'
' LICENSED CONTRACI"ORS DECLARATION ����
ADDRESS ( ' NO.
� !hereby affirm ihat I om licensed undor provis"rons of Chapter 9 r j
, (commencing with Sectian 7000)of Division 3 of ihe Business ��f�
�. and Professions Code,ond my license is in full forcep d effect. GITV CLA55
��- bESCRIPTION OF W0 K FINAL
', License Number�.��� Lia Class��•��n SWIMMING POOI DATE �- �'.O�3 7.Z�i n
� Confracfor�;,�•'��� � Dafe___ye!�� SPA � FINAL ' ��,o 0 0 0�?'�
❑ SQ.FT. eY �"
-I am exempt under Sec S�ZE � �, c(;;j,`., h
C7
t.)
'� B.BP.C.for this reason EIECTRICAI , ,,, _ , . C�
Date: U
, Signature � Steel&Conduit Bonding d� �;;,'� `q - �,„ �
, Conduits,Conduciors,Equipment �� ��g,� � ,
- SiNGLE FAMILY
�i HOMEOWNER-BUILDERpECLARAiION pLUMBING - � �
I hera6y affirm that I am euempt from the Coniractor's License �
�, Law for ihe 4ollowing redson(SeUion 7031.5,Business and p_Trqp a��•r��
. Professians Code}: Gas System �
��� � I,as owner of the property,will do fhe pl�mbing cnd Anti-Syphon �G�x ,-�,��Vf��o'` '
ele<iriml work.I,or my employees with woges astheir �'��
� sole compensa�ion,or a�icensed coniractor will do all MECHANICAL ,���L /,,�'t;T"i?'« -
, other work and the strudure is not intended or offared �
' for sale(Seciion 7044 B8P Cade). Swimming Pool Hetlter
� CONSTRUCTION LENDING AGENCY �
I hefeby affirm that thare is a consiruction lending agency for �-qpp�ICAN� TE� �,/+(]�^/
the performance of the work for which-this permit is issued (pR�ry7J NO.�Y`G (`(� ,
(Sec.3097,Civ.C.).
Lender's Name AODRE55 .
� Lender's Address �
', P.C�Fee$ � �'�� Permit Fee
' I certify that I have read ihis appli<ation and stote ihat the �
��, above informotion is c rrecf.I agree�o comply with all Coynty Issu e Fee
� ordinances and State laws relating to buildrng, ele<trim�, �
� mechanical and plumbing construction,ond hereby authorize Investigation Fee . ,
ati of this County to enter �pon Ehe above- Total Fee
� n e roperry fo inspection purposes. �
�I S�g�awre of Appl'�m�or Agem �� Onre `'' � SEE'REVERSE FOR EXPLANATORY LANGUAGE
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