HomeMy WebLinkAbout1082A 1344A (5) WORKERS'COMPENSATfON DECLARATION - ' � '"' �� ""�� � :� ' ; �"'`�'.. '. � �-. - �
� 1 Fiereby affirm ,f,o,�ha�e a�e�t.,.�ofa of�o�5e�}�o=e�f APRt[CATIQN-F.OR� COMBINATtON�-SWlMMlNG�Pfl4E���PER�MIT
insure,os-a tertificore-of�Workecs'Compenwtion tnsuronte; � "-�-
or o cenified copy thereof(Set:3800.t b:_�.) -76Aype - . . ' - __ - ----- ----.--- . .-
._ __. .-.: -:_ __ .._ ..._._ .. --------
CE8761a/�) - .. --
Policy No. 0 J Compony - _. __ .. COUNTY.OF LdS ANGELES _ BUkLDING AND SAFETY �
� Certified copy is-hereby fvmisF�ed ` � - �y�'
� Certified copy�is filed with the�c0un}y.6uitding inspet- � �.�R f��-��'NT T��F���1��-�'-�-� . -. p�DRE55 V aiJ � ...t �
Mon departmeni. � BWtD11VG , . ( i2,- ' � � �
�Dat�-�'r-3—Y�.. APPliton ADaRE55._. .. .. . l.cl ... � 1�OUttfv._ . . p JJ � � . . ., ..
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CERTIFICATE OF EXEMPTION fROM WORKER5' CI7Y . I�� V� 21P � GtO555i._
- " -�- ----EQMPENSATtOfY-INSURANCE _ S�ZE O�. .¢L r, ASSESSDa - �-
� TRACT lOF LOT NO. .&v . M4P BOOK. PAGE PARCEI �
(Thia saclion a�d nM 6Q swupt�lod'rf fba�p�rmk is fw wte � �_ �y µqp -�
hundnd dollarf(Sl@Q��or lass_)�.. .-.. _. OWNER � NO.- � .
�I certify that in the-perforfionte of�-fhe wdik-#or�which tFis �) � � rC n / (�\ SpECIqL
petmit is issued,t shafl not emptoy a ny person in ony rnanner ADDRESS !�, f;L( "'i-� ��1Tt�15-
w os ro become subject to the Work�ers'COmpehsOfiOn COws.- -'-- �OISTRICT 'STAi16TICAt QAS$r � TVPE �- Ppp�$$ED gy �
. ' . . . . CIFV N�O ZIP �I � • .�, i CbNST. . ... . -
Date .. - Appficant -� - � ARCHf'iEC7�2 � TEt.� . .p� UASSNO. ., ' .
NOTICE FO APPItCAFVT:lf;�-ofrer--mnking-ehis Certifimte of �'��R � �� t
Exempiion, you should--l�ecome�svbjecF�to the-�YYarker� YALUATWN �-� ` '
Compensotion provisions of the lobor-Code,you�mu51 farth- � i4fl�R€� /� / 3 '4 f` '� �� YALIDAT
�
wiFh comply with sucR.provisiaas ��.1his�permi! shall-be � CONfRACTOR �f � C.. �t�.t,7+Z� � s ��/ `���,' +': .
deemed revoked.- '� . .
- UCENSEQ CONTRACTORS DECLARATtON � ��� '"� � � � -
!h �ehy aff'vm thoi.t am licertsed vnder provisions of Chopter 9 ADDRE55 $Gf�qE�EjC LNO. � _ �
(c mmerKi�y.+nth Section 70t�0)of'�ivfsion 3 of the BvsFness . �TY � ���� GASS- � �
Ptofessions CarJe,a�d a�y{icense-is M fitH force and effect:- €�SCRIPTKNJ OF WORK � _FMIAt / p � : .
License Number�3�&>'t( uc C�ass� swinaainic aoa � - owte f1-7�p � �e y��' �1 Q�8 2 A ��
Contracto��L/N_l� Dote9 -3"f7 SPA � � fINAL e • � O
. - 54.Ff. �y }�• ♦'�J'�- V
f am exempe under Sec: 5� � ' J�b 5� �
B.BRC.for this reason � � • �
ELECTRICAI . �"-
- Date: . � . . s m s�E.��c�i t_Vtl
Si notare - . .. Steei 8 Conduit Bonding � �y-� lB�J� : . - � �
9 ___ __ ... . Conduits,Conductors,Equipment ��� ��� -'_. . �i�2 E��-7 �
._ ... SINGlE FAMILY � '-- , . �
� HOME OWNER-BUILDE&{21FGkARATION�.�.� - _. .. PtUMBtNG � . . .���� .�. ..
IherebyoffirmthotFomexempefromthe[ontrodoPsticense � -- - :� �
law for ihe following reasrsn-,(SeUl.on"7031.5,.8usiness and � P-Trap . . . .. � � - - .
R'ofeisions Code):- "' � _.. �.` � Gas System . . . � � . �.
f'� 1,as owner of itte prope�ty,w�ifl do ibe plumb(ng o'xi Ann-Syphon _ L^x��W`��� _ -
v electAcafwork.f,or,myemptayees_with_wagesoslheir__ ' � �f_� � ' .
sole compensohon,ur o-licensed caniroupr wilt do ol[ MECNANICAL � . �O/G ��-r��-� -
� other work bnd Ihe-siructure is-nnt inteeded or-o£fered� � � - - . -
for wle(Section Y04a B&P Cod�e}. Swimming Pool Heater � _ � � - � -�-- -
. CONSTRUCTIQN IENPING AGENCY � -
�here6y affirm that tbere is a co�struc�ion Iending agency for - . � . -
the performonce of the werek fw which�this-permit is issued- A�p�jryT� � _ _ - .. z�.�. �4{�
(Sec.3097,Civ.C.). . . . . ..
� ,�... . .3
Lender's Name _.._� .._.. .. ADORESS-.._.___.__.—._ ___ . . .
. Lender's Add�ess .. . .. . - ..� / r . .. �1 `_ . . .. � a 2�Q�J Q .
.. -.._._� P.C.Fee S �`•S� Permis Fee !�0�..,. �' �
1 ceh�fy tha�1-hove read this opPiicoriom and state that'`rhe - - - ����""`"^'•'�_-. 3 n �4 i� •.•G�U.rj(1��-,
above informat�ort ismnect:+agree tvtomply wiih uftLoortty- " � � :���t�i�'�,, ' - -
ordinonces ond Slate lows reloting-io building, elechiml, lssuanm Fee .- , �9��4 q�7-
mechanical ond plumbing tonstrucdo�n,and hereby Quthorize ��vesriga�wn Fee.. -rJ���O t -�-- " � �- �
representofives of this County to e�nler upoa Ihe above- TomlFee ��� .. �
menfioned property for 7n5p��� pv�pose5. . �
S�`�� . . . � - - . .
5�9oo+u.e of pplimm o.age�� Da+e SEE REVERSE FOR EXPtANATORY LAHGUAGE - � � . ,
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