HomeMy WebLinkAbout0906A 1414A � WORKERS'COMPENSATION OECLARATION � � �/"���� � � � �
�iJ hereby affirm�ha�I have e cerlificale af consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT �
/ insure,or a cerfificoia of Workeri Compensa�ion Insurance,
or o�erNfied copy t�f(SPc.3800 Lob�� �e.+zoe - . . - -- .. . -.. . . . .
/yAIJ/" CE876 13/81)
Poiic No.lK_!.7 Com an . COUNTY OF LOS ANGELES BU1lDING AND SAFETY
� Certiiied topy is hereby iurnished.
AAA��� -FOR APPLICANT TO FILL IN BUILDING, �
� Cerfified Copy is(iled with Ihe Cou t buildieg inspet- � � � � ADORESS
�iOn depo��meni. BUILDING -
�,���,�� ADDRESS ����TY
Da�e��Applicon NEAREST .
� CERTIFICATE OF EXEMPTION FROM WORKERS' CITY 21P . CROSS ST. C��
COMPENSATION INSURANCE � 1 p �Z ' FlSSESSpR
TRACT ��b a lOT l0T NO. , MAP BOOK PAGE PARCEL
(Tbi.s«tion n��d nof b�compl.Nd i(fhe p�rmif I�for on� TEL I15F� ONF Mnv - �� � � �
hundnd dellars(SI00)er I�s�.) � OWNER No. p j�a N�.
I ceniiy tha�in�he performance of the work for which this !� SaEan� - -
permil is issued,i sholl no1 employ ony pe�son in any manner ADDRE55 �}�� CONOITiONS -
so os lo become subjecllo the Workers Compensalion Laws. � . DIS �CT STATISTICAI C14.55 1YPF PR(KESSEO BY
CITY ZIP CONST.
Date "� APPlicanl . . . .. naCHiTECTOR TEL.' �� ClAS5N0.� � � (�
NO710E TO APPUCANT: If, aRer moking this Certiiimte of ENGiNEFR NO CJo� �
Exemptio�, you should bemme subjed to the Workers' - ���- � �
VAlUAT10N
Compensolion prorisions of 1he tober Code,yoo�m�st ferlh- ADDRE55 � � . .VpLIDATION �
with comply wilh such provisions or fhis permit shall be ' CONTRACf -.T�jp,9 q S / ���-
deemed revoked � � �
IICENSED CONTRACTORS DECLARATION ���' � - �
� AO�RE55 , NO.
I here6y af(irm tfiat 1 em licemed under provisions af Chapter 9 ��� f �� - � � � �
(mmmencing with Sec�ion 7000)of p�vis�on 3 of the 8usiness �,t � ewu 1C- � . �?0 9 0.6 A .
and Professions COde,and my license iz in lull lorce and effect. DfSCRIPiION OF WORK �--77 �
/� IY�I FINAL // y�• • �.�'Z.�
�LicenseNum Lic.Class`-� SWiM/d�NGP00t �r � UA73�_('�v , � . 0.
Conlraclar Dale����� o� SPA � � � � FINy � ' - � � • •4 1,6 5 U
� I am exempl onder Sec. . . . SO.ER. ... . ... ��� �V� - a�e .�L�,6 J csi O
8.8P.C.for this reason ELECTRICAL.. - . . . . • � S�(�l\\/?., . . .. O E�.2 O"8 7 U
De�e: . � v�ti iw��\
7�� W
Si noture .. . Sfeel 8 Conduif Bonding . . �..VR/ _ ^�.� 1 � . �
9 Conduils,Conductors,Equipmenf l `N ��`� �p Z
SINGLE FAMILY � �� � � � • —
HOME OWNER-BUIIDER DECLARAiION pLUM01NG , • � . ► , .� � n , . � - � �
I hrreby oifirm Iha�I om exemp�(rom�he Conlroclor's Litense . . . . . � \\ �
Law for ihe following reason(SeUion 7031.5, Business and� P-Trop - � � . � �,��'?`y �
Protession:Code): � _ � � . GosSys�em � � - � - � ���� • � . .. . .
aI,os owner of the properly,witl d0 the plumhing ond A��i-Syphon � � : � .
eiectricvl work.�,or my employees wi�h woges as the"�r . . __ .
sole compensa+ion,or a licensed mmrodor wfll do oll MECHANICAL .. `� (�1,(`A
olher wark ond Ihe Strocture is nol intended or offered � � � �� � � . - -
� fo.sale(SeUion 7044 B&P Code�. � \ Swimming Pool Heoler ' �� � - . ��e•• • • •3
CONSTRUCTION LENDING AGENCY � - � - .
I hereby affirm ihat there is a consiruc�ion lending ogenty for APRiCANt � TEL � � � - - I ° � 5 a 5�
�he perFormonce of tfie work(or which ihis permit is isst�e\d (PRINT) � - � . � - NO. • � � � , • ° � ,�j(�,J Q v
(Seo 3097.Civ.C.). . . � �� � ' .- ' . . � . . n
Lender'S Name ���� � ADDRE55 � � ' � � �� � � ��� � � ' -� �g'V 9_8 7
Lender'S Address � � p,�,Fee f 1��S Permit Fee �T�"�� -�� �
I cer�ify tha�I hove read this application and state�ha�Ihe �} ' � �
obo�e informotion is co�recl.I agree lo mmply wilh vll Cooniy � -- � Issuan<e Fee ��D�`�v � � �
ordinances and Sta�e lows reloting to building, electrital, , _ , __ ,
me[haniml ond ptumbin9 mnstruction,and hereby oWho�ize- ��ves+igoeon Fee �-y� (�)
� represenia' s of �his Cooniy lo enter upon the above- To�ol Fee �J�•v- _ . . . �
meNioned pr rty fer inspection purposef. . . . . . . .. . .
-�..L- `�-/�-&J .
S�gnon�e o App6co�t or Age�r Dare SEE REYERSE FOR EXPLANATORY LANGUAGE
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