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HomeMy WebLinkAbout1766A 1767A (10) WORKERS'COMPENSATION DECLARATION � ' ;, . � � � I hereby ofFirm�hat I hove a ce�lificoie of consent to self . - insure,or a certifica�e of Workeri Compensa�ion����,a��e, - _� APpLICATION FOR COMBINATION.�SWIMMING POOL PERMIT � or o cer�ified copy ihe�eof(Sec.3800,Lob.C.) � . 76a20a .. . - . . . . . .- ' . � . � CE818�3/9e1 Volicy No. Compony COUNTY OF LOS ANGELES '` BUIIDING AND SAFETY � Cer�ified copy is hereby furnished. � - � ' � � �- � FOR APPUCANT TO FILL IN BUIlDi�3 O Certified copy is filed with the coonty bailding inspeo � aDoae,; �,S fion deporimenl. - BURDING / _I �q/J� " � � � � - A�DRESS / P/77dN V(/ LOCALI�Y Da�e � Appliconf ' NEARE57 CERTIFICATE OF EXEMPTION FROM WORKERS' � - ��� Nv� Z�P �7� � CROSSSi. COMPENSATION INSURANCE . J� SiZE OF ASSESSOR TRACT �V LOT LOT NO. � MAP BCOK PAGE PARCEL �(Thla s�ction n��d no1 b�complN�d if Ih�p�rml}{s(or ono - . EL. ZONE mnP hondrad dollon(5100)or Issc.) OwNER � �.�cr ( . �.�� ' � � Np. ��"' 3� -� � I certiiy iha�in the periormonce of the work for which this � '/ n �� � SaeCiA� permit i5 issued,I sholl not employ ony person in ony monner ADDRE55�Y IS ���r�d� C�� � � CONDITIONS � �� �� � so as�0 6ecome subject fo ihe Workeri Compensation Laws.- - � D DISTR�Q STATISTIC4L CLASS TYPE pR EO BY pTY W��YJ�+ 21P �]p � �55 NST. n Dale Applicanl ENG N�FERT� NO.SS 7"�� � � � ��"' � NOTICE TO APPLICANT: If, after making this Cerlifimfe oi Ezemption, you should bemme subject to the Workers' �� - � �� � VAIUATON - - Compensation provisions oi the lobo.Code,yoo�mus�forth- ADDRE55 T �� �' ' VAIIDATION ith comply wilh suth�provisions or Ihis permit shall be � S (� , deemed revaked. - CONTaaCrOR �- � � � LICENSED CONTRACTORS DECIARAT10N uc � � � � � � � �� � . � ADDeE55 � - L- NO. - '� . �I hereby 6ifi�m ihat I-dm licensed under provisions of Chapter 9 , ��� S � .. . . . (commendng with Section 7000)of Division 3 ot Ihe Business C�n, , CLASS • and Professions Code,and my license is in full force ond effect. oeSCRiaiionl oF wOeK � � FINAL `1 7 Q�� Lirense Number Lic.Closs �SWIMMiNG POOL � � � - DFTE- �— ��--� , - . � } �( . .'.�� n: Contraclor ' Date SPA ' FINAI �� � �� - � Q • so.Ft. .�•�g nr� 1 • •7�5 1 C ' � � �I am exempt under Set. SIZE �B.BP.C.for ihis reason � . EtECTRICAt . _ . . . - . .�, s a e'f y,j 7� � Date: W $i nolure . S1eel 8 Conduit Bonding� ... � � .. �!«2 J—C� p, 9 Conduits,Conductors,Equ�pmen� . . ��- � N SINGLE FAMILY � �n.��,�,i� ) =�� 7.h I A � Z - HOME OYINER-BUII�ER DECIARATION PLUMBING �-- � - - ����.f��iC.Yi� u a . „�e .z I hereb y offirm thot I am exem p�from the CoNraUoi i License F� � � T "� Law for the Iollowing reason(Sec�ion 7031.5, Bosiness and � � � � � �. L/7(i Op : .. c � Professions Code): � P�TfOp �� � � ��� ��`''`�U � Gas System ; q � I,as owner of the property,will do the plumbing ond Anli-Syphon - -- � U ��� /y-�• '� •..+^:�.;i�.�? electrical wark.I,or my employees wilh wages as Iheir [��J ������ sole mmpensalion,or a licensed mnhactor will do all MECHANICAL� �� - �- ' - � . ���/_ ��C�,—?(� o�her work and ihe structure is nor imended or offered � (%� �, ��. , � for sale(Sec�ion 7044 B&P Code). - 'Swimming Pool Heo�er • , , . , CONSTRUCTION LENDING AGENCY - ' . . �I hereby aifirm that ihere is a constraction lending agency for � � the performonte of the work for which this permit is issued APapgjM��L�C� � N�' S5(/'•• � � � . (Sec.3097,Giv.C.). � _( ,j� /. I � .. . lender's Name qooRE55 �S/`e����V (7��� "�/��� , � lender i Address � _ �/� � � ' � . � � P.C.Fee S - � Permu Fee w � � I cerfify Ihat I have read this opplimlion and sla�e thol Ihe - � . �� � - above infarmation is correct.I agree to comply wi�h oll Counly . .. .. - . . . . ordi a ces a d State laws reloting to 6uifd'ng, eletvi[al, Issvance Fee � . chanical o d plumbing construct�on, er au� rize ��•esngaro�Fee /� . . . . epresenra�i s of Counly ro the ove- � � " � Ta�o1Pe .Q`� � � mentioned rope y r inspettio o s. Jy�� f/ /�✓�� / '�G'J !/ CJ gnat e Ppp�ican or ge�� Dote � � SEE REVERSE FOR EXPLANATORY IANGUAGE - ' . o ° � � r O � m y G1 (i y � � � D r Z � ^ O = q G� � m � p A Z ,G-� � p� 7, e� o. l� — � m f1 q 'C � m 9 C � � A � T � � O n a � N .�+ rrn � - m L � . � r . r � u+��n D p O �n � A Z r �0 A m •�- � 7i ' .rR T � N y - �' - A Z r Z Ny � � y+O '^ ' O ' O � � Y c� o s y , o � '^ .. 2,G+ ' � - o � . �° � R� G r � � N ;p � D � � � � � . C 'p. .Z.1 ,�' � i � �' �. �• . 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