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HomeMy WebLinkAbout1645A 2110A (9) � 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 F . � � o g m � � o m � � � �' o z i � a -^ � q ., � y' N Z � /1 Y� O T � y Z ^' -Zi �. p '" G � O. � 2 N '. 'y '° C1 �s„ Z G N m �• < ' = ^' "'� . . 0 � �" O A O N � r X = n S . T � N � O r r �^ � m a O n '.� (1 � 7 p 2 A � ��n io � . . �o m � a p' m m .z�r N �C - Z Z v�' n . - [� p �-n Y i '� . y .-i ,D,� y� < . 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