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HomeMy WebLinkAbout1317A 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�` �,l �.�p, ! ' 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- ADDeE55 � � 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 Conduit 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 : electrical work.I,or my empioyees with woges os 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.). � , - - -�'� ,�C� 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 'ves 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 - � � 2 0 o- • . � � � 0' � �� ' f+ 1C` p �� fn p � ` t �" O `(� -n i N 7 � z• �.Q O v'V p ,- ' � M � � G � �v' �` n ��, �n �j°^ 2 :� �' 'L =� ':� G ..� � x � N X ^` G .:� O - � . � " ��++ '" %' � � � Z o . N n - x > o � x o � � a � �+ � Z ��� � �a Q 9 �, � S ��, + � � � O a �n r� K, 1 �r � �` y ' t � . p � N n � T�n � ' � �e � r i ' � � ,�'p o �2„ O A � q� a e0 ` p - c r � „� C� a0 � .� f� N ➢ Z".. � � Tn O A ~ � '' p �ii (,N Cr � `Q Q a a ' m. � -/ �� �.c, �� � . � �` -�� �'� / � � �2 , J � y� '�a 1 ' � M ,i i S ; ; • . 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