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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