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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 x a , o . .. � _ . � _ � T !1 . n Z = � � N �L �' 0 d � p ~O Z �' � • - ! � . N � ^ O "� t/� . � � M a '� �o � � c t+ y, p "� �i � Z 'X :.� . ❑ �M � � n O T T A. .N[ �i Z T �I N .�1 i q � Z C' yr ^ T It� � '4 p D Y '_ = z^' L p � Z . � ' O .�.. 7G m � N •$"''1 N �. ` . Z T m �y '4 � � � ��.1 �i .rj�T q }�, t/� � 7o Z r !, . -� � � f, G� q�o � � •.� o O q � � n u, C i. . 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