HomeMy WebLinkAbout1645A 2110A � WORKERS'COMPENSATION DEGLARATION � -� � (�1(/��D��-�� � � '��� ' � '� �
I hereby affirm ihot 1 hove a certihcote of consen�to self �
insure,or a certificate of Workers'Compensalion��5�.a��e, . � APPUCATI4N FOR COMBINATION SWIMMING�POOL.PERMIT
or a cerlified copy thereof(Sec.3800,Lob.C.) 76n2oa- - - � � � � � , _ . -
CEB16(3/Ba) � ,
Policy No. Company COUNTY OF LOS ANGELES BUILDINCAND SAFETY
� CertiFied copy is hereby(urnished. -
FOR APPLICANT TO Flll IN euaoiNc N,�,
O�Certified topy is(iled wilh the tounry building inspec- " A�oRE55 � /� Y�l.bW'� � � �
rion deportment. . � � . � eWtoiNG /� y� -
. . ... ADDRF55 � ��V I�� - � LOUIITY. . /-�.... .. . . . .
Daie Npp�iCanl J�' . I O / NEAREST
� CERTIFICATE OF EXEMPTION FROM WORKERS'- � ��tt �7MON ZIP . (�,�...-" �ROSS ST. -
� - ' COMPENSAT�ON INSURANCE - S�ZE OF [� ASSESSOR � � ,
iRACT . LOT LOT NO. �JZ - MAP BOOK . , PAGE� . PARCEL
(Tbt�fodien n��d nof b�eompleMd if IM p�rmil l�fer on• TE�. u NE � MAP �
hundred dollan(S10D)or lass.) � OWNER '�11�L �""� R t ivo. (nf, � �'p� � ra.�. �� � �����-�3 ' � - �-� -
I certify ihat in�he performonce oi ihe work for which this�� �a� SPECini � -. - -- . � - �� �
— permil is issued,I sholl no�employ an erson in nner ADDRE55� � /� � V 4 J COND�TIQNS —
so as lo betome sobject 10 the Wo� r o p so DISTRICT STATISTICAI MSS iYPE VROCESSED BY
CITY ZIP � . ' ' CONST.
Dale A IicoM � ARCHITECT OR 7E� /` 1 � QASS NO. �
NOTICE O APPLICANT:pinf, afler makin his Cerlifico of ENGINEER • �. ,f NO,(p Z ` J ��
Evemplian, yau shauld become subjec lo the Workers' ADORE55 � � VALUATION , � , �
Compensalion provisions of the Lobor Code,you�must forlh- �" � . VALIDATION�- -
with comply wi�h soch provisions or ihis pe�mi� sholl 6e -� �� � TE�� f l/ �v7! - .
deemed revoked. COHTR.nC�OR �NO / _
� LICENSEDCONTRACTORSDECLARATION � ��-. � �tJ-���'��95/D �
I hereby olfirm that I am licensed under provis�ons of Chopter 9 ADDRE55 i O. _ � � ,
(tommencing wi�h Sec�ion 7000)of Division 3 of Ihe B�siness ��n, D�1/ QASS /�� � �
and Pmfessions Code,and my license is in full force and�efiect. DeSCeianOnl OF wORK
fINAL
License Number-�;,�s3;q yl�i'�:eio:: -L'Jr SWIMMING POOL ' . . . . DATE�"`��--�'� � � � � �� 6 4 5 A.... >=
� U
Conlrador �O�PH�� P�^'V Date Q l SPA �--. . -. . . .
FINAI � ' #• ► • •`�?�
SQ.FT. � 6Y �� .
�O- I am eHempt undei Sea SIZE .. . . . .. . . . /� ' . . , ."I'•.•�2 Q 1 O
k�
8.8P.C.for this reason � . .. � . �'`•~:..:. .
EIECTRICAI � . . .. � . . � . ... � .... . � .. x ~
Date: 1��� ,p/� . . . . . __. i ° •528�1 c� W
Si natwe � ' Steel 8 Condult Bonding- . . . � Lr(.d. p,G.,/. . '� . .. . �O 9.� u"H�I�: [n
9 Canduits,Conducrors,EquipmeN � , Z
- � SINGLE FAMiLY -. . .. � ` '� —
HOME OWNER-BUILOER DECLARATION PLUMBING �aZ��_�, � �-
I here6y offirm iho�I am exempi from ihe Contractor's Litense _ . _ .. � . :�� � �'
Law for Ihe following reason($ection 7031.5,Business and P_T�oP � .
Proiessions Code): � � � � �
- - Gas Sys�em ��� � . _ , _
� I,as owner of the property,will do the plumbing ond Anti-Syphon "
electrical work.I,or my employees wiih wages os their ,. _ � ��
sole compensa�ion,or a licensed controUor will do oll MECHANICAL �
o�he�work and the shucture is no�intended or offered ,�f �� �� �- • - -
for sale�Section 7044 88P Code). � Swimming Pool Heater LJ .. ��—. ..., ', � �2�� ��O A
`
CONSTRUCTION LENDING AGENCY . . � �� � . � �� •� • •J
I hereby affirm thallhe�e is a conshvction lending ogency for �� .��� �� •
the perfo�mance of�he work ior which ihis pe�mi�is issued AP�PR ry�) AvL, � �� YNO � , � ' i a a b�a
(Sec 3097.Civ.C.). . . _ . .. ._ . . . . �
Z O,f�11�0�/�✓a CwJj • • i aaoo�
lender's Name ADDRE55 _ � . ..
�j �-7� ' 09.24-87� .
Lender's Address p.G.Fea E ��� � Permi�Fee I�/'`� V � � � . � � � �
1 certify Ihot I have read Ihis applimtion and s�ale fhol Ihe � � _ ' ,. . ' � �
above informofion is correc�.I agree to tomply wilh oll CouMy'� � � � • � /Q�� � ' � � . . ."
ordinances and S�ate laws reloling fo boilding, electricol, . Issuanm Fee , � , .
..mechaniml and plumbing conslruction,and hereby aulhorize Invesiigoiion Fee ,/� . � a, � � � �� � � ' � -
iepre atives oi 's C oNy 10 enter upon the above- To�ol Fee . � � �
mr ri ed r e y r i peclion purpOseS. . . _. .. . , �. ,. ,. ,. .
s�goam.e f ppL m o. eo� � SEE REVERSE FOR E7CPtANATORY LANGUAGE
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