HomeMy WebLinkAbout1178A 1317A 1701A ' �--- I
WORKERS'COMPENSATION DECLARATION � � - � - � �
I hereby ai(irm ihat 1 have a certifimte of consen�to self
��,�,a,or a certi(icaie of Workeri�o�,�nsation��s��o��e, APPUCATION FOR COMBINATION SWIMMING POOL PERMIT
or er i ied o y thereoi(Sec.3800,Lab.C.� .�yqZpg - �
�bl�c� ��r,r t�c �.a�5,,,,a„ . .
Policy No. Company,�� � COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy ts hereby furnished. �� - - ' - � ��
� Certified co is filed with the coun� buildin ins eo- FOR APPLICANT TO FILL IN eunoiNc /r9
�,{� PY 9 P A�DRE55�-
�' �7' /���• BUILDING
'/�jy� J ADDRE55 I � �IDU1�L/�ffT mm�,! : iocnun - 1S���
Date_�� '. ApplicaN � - � NEAREST , .
CERTIFICATE OF EXEMPTION FROM WORKERS' CiTY �yYIlSRf� F�ZIP - _: CROSS ST.
- � . COMPENSATION INSURANCE . �(` /' SIZE OF nS5E550R ,
TRACT �/—`�b lOT LOT NO. MAP BOOK i PAGE � PARCEI �
[Thh s�ction nNd net b�complafod B ths p�rmit 1�ior one �G� N i.,__�. _ U ZONE. MAP /�/+�_ �
hundrod doUcrt(5100)er lau.) � OWNER O�`-J�` �,� nio. ! C.O
I cerlify thal in Ihe performonce of the work for which this- ,g SPEGAL .. . . . .
_ pErmil is i55oed,I Sholl nol employ any person in nny monner AD�RESS l'�i '��V� CONDITIONS� —
so os to become subject to the Workeri CompensaliOn Laws. ' . -�'� ' . DISTRIC� STATISTICAI QASS iYPE PROCESSED 6Y '
� � - CITY � ZIP CONST. �
Da19 Applimnt � ARCHITECT OR - --- � --TEL. . . . /� �SS NO.�� � .
NOTICE TO APPLICANT: If, afler making this Certificate of ENGMEER - NO, L ,
Exemption, you should become.sub�ect to Ihe Workers' � � � � - ���- � --��-� � y/UUATION �
Compensetion provisions of the Lobor Code,you�must forth- Ao�eE55 � �
with compiy with wch provisions or �his permit shell be TEL. - s � JZ-� - � VALIDATION
deemedrevaked. � �ONtRnCT 77�. LSGL .n10� ���" � � .
IICENSED CONTRACTORS DECLARATION. �y� uC. / � . . �
ADDRESS Q� �IGE?l S NO. / - . .
I hereby offirm that I om licensed onder provisions of Chapter 9 � ��� s . ._. . . .
(commencing with Section 7000)of Division 3 of the Bosiness .. _.. � �
ond Professions Cod '.end my li nse is in full force and e(feU. C�N /�Ei��C- -ClASS�� - � ��� O �_
v/7 �/''/ (/•�� DESCRIGTION OF WORK FINAI / �''7
License Number �"�/�� Lic Closs `� SWIMMING POOL � � p�� _L�� / z� � �' . V �
/ , ��� �,
�,/ v # 23 O
-FINAL
Coniracfor �"" .Daie � - SO.FT- L-y�� . .. ... .._ 6Y V
� SIZE J / . . 1 • �a 4 4. . w
�I om exempt onder Sec. y
' B.BP.C.for fhis reoson ELECTR�CAL . _ _ . . _ ... . _ . ' � - • °7�U 4� Z
Dale: B � -� 7�Q 8—�i v
Signoture Steel 8 Conduif Bonding � �� -� ��ey� � .
SWGLE FAMILY Condui�s,Conducrors,Eqvipment'� .
- �� HOME OWNER-BUILDER DECLARATION � PLUMBING . ��� pZ SS 73 - � - '
I hereby affirm ihat I am exempt from�he Coniractor's License � � - :
Law for the following reason(Section 7031.5, Business and- P-Trop � � � � ' -
Professions CodeJ: � - Gas Sys�em �' . .
� I,as owner of the property,will do the plombing and Anti•Syphon � - � �� - . z� "4•7 A :
elecnical work.I,or my employees with wages as iheir , _. .,_ ,_._ __ _. _ �� � � ��.�
sole mmpensotioqor a licensed confmttor will do oll MECHANICAL � " . �
o�her work and the structure is not iMended or offered .� � '' .., . . . � . I ° °v 2 8.� .
-� ��� for sale(Sedian 7044 88P Code). � �� � • $wimming Pool Heoter � -� �� � ��
CONSTRUQION LEN�ING AGENCY � � . e e e 5'Z,�i� u ,
I hereby a(firm Ihal there is a canslruction lending ogenty for APttIG4NT n �- - � �� � -
the performance of the work for which this permit is issued (pg�NT� �('-S�ZfJ J—'L Np�'�(�— � G 7,1 2-8 5 ��
(Set.3097,Civ.C.). , _ _ L 1 ,7�'1 A
Lender's Nome � ADDRESS -� � � �
i �
-- - 11o . . . e3
lender's Address �Q '7 � � � �
P.G.Fee 5 ��� "/. Permit Fee � ��/• � . � -
I certify th ave read this applimtion and stote thal the , � �,• � ��Q� �� �
above' rmo�ion is carrect I agree to comply with oll County . . _ . Q,�( - - - � '
ordi onces and Slale laws relating to bvilding, electrical, Issuon<e Fee � � v� •�A 1 8 B.0 0�
mecheniml and plum6ing construction,and herehy authorize �mes��gar�o�Fee � � �� � .
represen 'vas o( thii Goonly fo eNer opon the above- � � To�al Fee ���• � � 0 7.2 5—8 5
meg ned p ty for' spetlion porposes. � � - � . �
\ , / .. ._ _ .. . . .
� 3ne re of App6com o.Agent � Da � SEE REVERSE FOR E%PLANATORY LANGUAGE - �
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