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HomeMy WebLinkAbout1090A 2287A WORKERS'COMPENSATION DECLARATION ' ° , . . �N N�O, � � , � I here6y affirm that I hove a ceriificate of consent to self � inwre,or o certifimte'o�-�Vorkers'Compensa�ion��,�,a��e, �� - APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � - �� or a cenit�ed copy ihereaf(Sec.38 oI].C.� ' T6A20B� � �- � - � - � � � � CE876�7/Ba) Policy No.�_Campany (�.' �COUNTY OF Ld5 ANGELES � BUILdING_AND SAFETY � � �Certified copy is he'rebY fwnished. � � � � � c 1 - Q FOR APPLI�ANT TO FIIL IN BUILDiNG 'yg. Certilied copy is iiled with the coumy building inspec• . � � ADDRE55� � - � �on deparlmen�. � � . . BVIIDING Q' n��� • � � ,y��--��'� ADDRE55 I Q L 'UIG[..1/ � IOfALITY G�� •p Datey�LApplimN � ' NFAREST ', /j_ ��� CERTIFICATE OF EXENIPTION FROM WORKERS' � ��TY � _ ZIP . _ C�t055 SL . �--,CLyLlra- � � ' COMPENSATION INSURANCE � � . r' SiZE OF � q55ESSOR TRACT T Z LOT . lOt NO. MAP BOOK. P�GE � PARCEL (Thii taclion noid nef 6�compl�bd li Tha parmif ti For on� � 1EL. p U5E ZJ�NE . MAP � hundred dollan(5�00�of lefi.) � - OWNER ` ry NO. � p d�YJ(1 NO. ' ����r��� ' � � I�certi(y that in the pe�(o�mance of the work for'which ihi� �� ��,y..1..� SpE�iA� . . _ � _ ,. — permit is issued,I sholl not empioy ony person in any manner ADORESS � � �+u v CONDITIONS � � - so as ro 6emme subjed ro the Workers'Compenwtion Laws.- ' . ' �ISTRIQ SiATISTICAL CLA55 � tYGE PROCESSED BY � CI7Y ZIP CONST. Dale�_Applimnl " AR�HITECTOR � TE�. C'1A55N0; NOTICE TO APPLICANT: If, ai�er making �his Certifimte of EN wEER NO. r O .l�. �� � Exemprion, you should,bemme subjecf to Ihe Workeri � ' ' � ���1 /` � VALUATION � - ^ . Compensotion provisi0ns oi ihe Lobor Code,you�musl(orlh- ADD4E55 (S7Q' (Jj'� � ,.�,�•\��;•{,`,� ��� " with camply with�such provisions or Ihis�permi� shcll be -� ' � - TE�•G/��y 2 S �D D�C/ . �� � - VAIIDATION . deemed revokBd. CONTRACfOR .NO..J7`1�.�✓' L�CENSED CONTRACTORS DECLARATION UC. C, . � - �� , � I hereby affirm thal I am licensed�under provisions of Chapter 9 ADDRE55 � G- 'NO.3,�[��� s : � - (commenting,w�M4Sec�ion 7000)of Drvrsion 3 of�he Bvsiness liC. �. j - - � � . .�and Proiessions Code,ond my licenie is in'full force and eHect CITV ,-- " LtASS �' .... ..�-'". . ��„�'c. , '�� �9�A � OESCRIP ION OF WORK.� rI�y�I / /' � License Numbe���� lic.Class� SWIMMING POOL � � �1 DATf``1jD��.�. ► -.' �• • • •2�'� a co�r,o�io.��l/�t a� ' Date��Z sva . �. FINAI .;��1- I • .4 5 3 7 p ' so.FT. s �-,- U � I em exempt unde�Sec �� 5¢E- :� �iCS - - . .-. . - . C . .. 'ij . ._.. . •�+ •�1�.J.7? CZ `� . ----- � '7J827=87 � 8.8P.C.fol this reason Date: EIECTRICAL - � . � . � � . /(��. ��4�� . ^. ; W' � !-N. � $i noture � , Slee 8 Conduit Bonding . � � �� [S � n-� 9 SINGLE FAMILY Con�ils,Cpnduclars,Equipment , � .�O I � - �'2`���]A ' z � HOME OWNER-BUILDER DECLARATION PLUMBiNG� � � � � �- - � - 't;• • • • •3 I hereby atiirm�he�I om e�empt 6om ihe Co hattor's License � ' 7 �X�` . Law for the lollowing reoson(Section 70315, Business and' � �� � �� � ' � ' � r U�Lt�,r p- � c � (j�j,�Q P-Tra Professions Code): �. � � , P . ��e�--�— � � Gas System • � a � 5 3, ' �� I,as owner of the properfy,will do the plumbing ond Anti-$�phon . . . , . , �n c=.�� � eleUrical work.I,or my employees with wages as Iheir � sole compensalion,ar a licensed controdor will do all MEC�HANICAL � � - � ' � � � � � �O� `�$7 olher work and the strvc�ure is no�intended or offered � . ,.. _ . ,.. ,,, .. , for sale�Sedion 7044 B8P Code). � • � � Swimming Pool Nea�er - � -� � � � -' �-��. _ � _;; � . • . CONSTRUCTION LENDING AGENCY , ' � - . . .. _. _____ . ._.. . . . I hereby affi�m thol Ihere is a consrruc�ion lending ogency for Ap���NT TEL�ry - � � - ' � ' the perlormonte of�he work for which this permit is issued .�pR�NT) NO 7q(�•3r' � ' � (Sec.3097,Ci'v.C.).�• , Lendei 5 Nome - ADDRE55 , .Lender's AdHress z , . - - P.C.Fee S Permil Fee '- - � � -'- ' ' I cerliiy thot 1 have read Ihis applico�ion and 51ate ihot the . . � � . . ' obove iniorma�ion is conecf.I agree to comply with oll Counly � � - .. . ,. . - - , ' � . �� . � � � ordinantes and Stale laws reloting lo huilding, electricol, Issuan<eFee �Q�; , . . - . . ical and plumbing construUion,and hereby outhorize �^��s��9a�ion Fee _� +� � - � --- .. . .. represe ta�ives of �his County fo enler upon the above- To�ol Fee - � � . - � memi n propQ (or'nspetlion purposes. . , � - � � � - � �� . . 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