HomeMy WebLinkAbout0905A 1415A � � � � /V�1.� � �:;,
WORKERS'COMPENSATION DECLARATION - � �
I hereby afiirm Ihal I have o cenificate of tonsem�o self APPLICATION FOR COMBINATION SWIMMING. POOL PERMIT
inwre,or o certifimte of Workers'Compensotion Insurante, � �
Or a terti(ied copy ihe�eof(Sec.3800,Lob. .) 76A20a � � ��-� - �� �� � �� � - -. . �
PoliCy NO. Company CE87B(3/B�)
� Cerrified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� FOR APPLICANT TO FILL IN sunoiNc
Cerlified mpy is(iled with the county ildin inspeo- � ADDRF55
- t(io.n deportmen7t, . BUII�iNG 10
7J,•�I9'$/ L. ' ADDRESS'� lOC.4UTY
Dafe Appliconl NEAREST LJ
an zia ceoss sT. - f� �W
CERTIFICATE OF EXEMPTION FROM WORKERS' -- -
COMPENSATION INSURANCE StZE OF 1 . A�SSpR
, TRACT . lOT l0T NO. MAP BOOK PAGE. PARCEL
(This��cHon ns�d nof b�eempl�4�d ff th�p�rmlr t�►er on� iEL Q USE ZONE htnP ,!
hundr�d dollors(5100)or lats.) � � OWNER p�p.f/ p�p... � .�• .
I certify that in rhe perfo�mance of the work for which this�� , ' ���q� �
— permil is issued,I 5holl not employ ony person in any manner ADDRE � CONDITIONS
so as to become subjed�o Ihe Workers'Compensation Laws." . DISTRICT STATISTICAL QASS iYPE PROCE$$ED BY
� � � � � CIN ZIP �: �(q55 NO.� CONS� �(�
Date - Appli[aM ENGINEER �L. D 10 C�j�rw
NOTICE TO APPLICANT: If, aFler moking this Certifitote of
Ecemption, you should become�su6jec� �o �he Workers' � � v�WAT�OH
Compensolion provis�ons of Ihe Lobor Code,yommust(orth• ADDRE55� ��
with mm I wilh svch rovisions or this - � � VAIIDATION
p y p permit sholl be - � . TEI. s ��Q��
deemed revoked. COMRA�fOR .Np. � '
.. IICENSED CONTRACTORS DECLARATION - - ���• - �
I hereby otfirm that I am licensed onder provisions of Chap�er 9 ADDRE NO.- • s .
(commencing with Secfion 7000)of Division 3 of the Business ���•
�� 9� �55�C s
and Professians Code,and my license is in full force ond effecL p�KRiviiOn�OF WORK
FINAL
license Numbe � Lia Closs� SWIMMiNG POOI OATE �'��--g ► �.0 9 Q 5 A �
CoMrotlor Dale � '��s^ SPA . . ... ... .. . � � fINAI� #� � ° �2� O�
❑ P soEFr. er � �` I ��4 1.6 5 �
��am e.em t under Set.
B.RP.C:for Ihis reason � ELECTRICAL. . .. . S p��_ . . � e e .�4 1.6�5� . v
Da�e:
Signatore � 51ee1 B�Conduil Bonding . .. . . . ..C� SS b Q O F�2 O`8 7 � p� I
SINGLE FAMILY Conduih,Conductors,EqWpment -� d�' � z
HOfAE OWNER•BUIIDER DECLARATI6N PLUMBING ►� � � � � �
�I hereby affirm that I am evempt(rom the Conrrador's License .� � ��� n �
�Law for the following�eoson(Section 7031.5,Bveiness and P-Trop � , .., 1`
Proiess�ons Code): � � Gos Sys�em . N [" ,��'_ \\ � - �
� I,os owner of the propery,will do the plumbing ond An�i-Syphon �5��1\l .�C7"�y � - �
electrital work.I,or my employees with wages os�heir . , . . . �
sote compensation,or a licensed con�mcbr will do all MECHANICA� � � -� � - � �
other work and the siroclvre is not intended or oflered _. . . ,
for sole(Sec�ion 7044 B8P Code). "� �- - -�"-� ���" -�� " � `1 �1.rJ A .
Swimming Pool Heater . . ,
CONSTRUCTION LENDING AGENCY ". - � . ��
I hereby offirm thaf Ihere is a construction lending ogenty ior . � ����a s •�
�he erformance of the work for which�his APPLIUINT ��. ' - - . . .
p permit is issued . (pRIM) . . NO.-
(Sec 3097.Civ.C.). � � . .. . I • 1 5 Q.5 0 .
Lender's Nome ADDRE55 .. . . -..-. . . . . ... . . _ . , .. . y ° � 5�j,j Q,3T
Lender's Address P.G.Fee f �1 �Q Permit Fee /�V�� � -- � - . . O 9 O 9�8 7 � �
1 cerfify that I hove read Ihis applicalion and slate thot the ^., , -
above informolion is correct.I agree to comply with ail Covnly � - � -- - . �Q,, U . . . - � .
ordinances and Sto�e laws relaiing to building, electricol, Issuanca Fee - .
mechanicol and plumbing consfruttion,ond herebyauthorize Invesiigorion Fee `r �
�eprezentalives of fhis County lo enle� upon the above- Toial fee /��•" � �
meNi ned pro r inspeUion pvrposes. - -� �� �
��/9-�� -.
Signatura o1 AppL�ent or Agent oaie ��� SEE REVERSE FOR EXPLANATORY LANGUAGE
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