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
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