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HomeMy WebLinkAbout1091A 1114A (5) _. � WORKERS'COMPENSATION DECLARATION � � � I hereby affirm thot� ha�e a cerfi(italP of�o�5en��o=e�f � APPLICATION FOR COMBINATION SWIMMING POOL�PERMIT insure,or a certificate o/Workers'Com ensation Insurance, or o certified copy ihereof(Sec.3800,Lob.C.) 76AZ(18 - � - � �� . . . _ . . - . CE-875 01/81) . . . Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished. �- � �� � - FOR APPLICANT T FILL IN euaoir�c a CeNified copy is filed with Ihe coonry buildinq inspeo- � ADIXtESS �tQ S lion deporlmeM. . BUILDING Q �^] / � � - ADDRE55 _L� ` l� IOCAU7Y I\I�1A Da�e - � Applimnt� NEAREST� ' CERTIFICATE OF EXEMPTION FROM WORKERS � Ciiv ZiP CRO55 Si. ' . � � � COMPENSATION INSURANCE SIZE OF ASSFSSOR� - � TRAGT � LOT LOT NO. H1AP BOqC - PAGE PARCEL (Thit feeilon nNd not be eompl�f�d It ths p�rmi}ti ior an� TEL. SE MAP hundr�d dollon(5100)or Ist�.) � OwNER I��A NO. O NO. � ' I cerrify that in the performance of the work for which Ihis �/�c. . .. SaeCiAt permit is issued,I sholl nof employ ony perzon in any manner ADDRE55 I�ky CON�ITIONS � — so os f0 ecome 6jec110 fhe Workers'Campensation Laws. ' ' � .OISTRICT STATIS7ICAL CLA � TY PROCESSED BY ' �-- �TY n�.a� Z�P � ) ` (- Dole' '� Applicant RCNI CT Cr-- ' - TEL � � ���� �L , NOTI E TO A PLICANT: If, aite�moking this Certificate o ENGINEER T Exemption, yoo shouid become svbjett �o the Workers Z� A �--:��.�� 6.G VALUATION � Com ensotion rovisions of the Labor Code, oa must for�h- /+oDRE55 /�C.� . � P YP Y � VAUQATION with comply ith such provisions or this permi� sholl be ��T��t'L°.�ti � - S � � deemed revoked. � � - ' LICENSED COMRACTORS�ECLARATION � ���L.t,� 1,.�� - ADDRfS — _ I hereby affirm thof I am I�censed under provisions of Chapter 9 ��� �v S �� �'9..� A (mmmencing with Section 7000)of Division 3 of the Business . . ' - (�-. � � } : ond Proiessions Code,and my license is in full force ond effect. C�iY � - -ClAS�' � ��..-e . e?j d ' DES IPTION OF WORK ��Nµ � i LicenSeNumber lic.Closs�^�� SWIMMINGPOOI . � �� DATE ��a� - .� iQ,�'�f::)� � � SPA � � ��J�^t� . .. O . �CoMracto r ate � � � � FINAG ',o�o:/_.; �� . H : SQ.FT. - 6Y • V � ��� I am exempt under Sec. S¢E � . � �'� �_;"� " y i B.BP.C.for�his reoson FIECTRICAL . - . . _. . .. .. . _.. �'/�I /1l..sj�. .. Z � Date: �7 V<J , . . . . .. . Signature C�nd uits,Condudor�,l quipmeM � . ��� - - � - � � SINGLE FAMILY � . _ , .__ . . .. . . _ � � � ' _ � _ � HOME OWNER-BUIL�ER DECLARATION p�UMBING �� � � � � �---- I hereby aNirm thm I om exempt from the Contrador's L�cense .� /�,�.y� � : Low for�he followinq reason(Setlion 7031 5 Business and � � . � /.7/�(./ � � � Professions Code): � P-T�OP K{� � . - ___.. . Gas System... . . � _ .__. . 1 . . . ' __ - .._ . � I,as owner of fhe praperty,will do the plumbing ond Anli•Syphon � � eleciricol work.I,or my employees with woges as ihe�r _ _ . . . . . sole compensation,or a litensed tontrocfor will do all MECHANICAC - - , � other work and ihe strudure iz not intended or offered - - � � . . - . � - for sale(Section 7044 BBP Code). � -- $wimming Poal Heater � �� � -- � - , . �� � �,(t A ' CONSTRUCTION LENDING AGENCY - . � � ._ � I he�eby affirm�hat there is a construdion lending ogency for �- .. . . ' . ' � � �.�% APPLIGINT TEL. � - � • ' i the performance of the work for which this permir is iswed �pp�r.�7J� No.� . ($ec.3097,Civ.C.). . _ .. . . . � 'L�Q.J U' .. lender's Nome � ADORE ( Gr� ��• . . • •C(1 Q.;Q? . . lender's Address � � .�y�`(? . � � �,� Jr—O J - P.C.Fee S� Permil Fee � �� . , . ' I cerfify thot I have reod this opplim�ion ond state ihot the � , � obove in(ormation is mrreU.1 agree to mmply with all Counry - � . �%l7J' � - - � . � , ' � , ordinonces ond$ate lows relaling fo 6uilding, elecfrical, Izsoance Fee� - . � me honiml and plumbing cons�ruUion,and hereby authoHze Investigonon Fea 5p � r r, T' ,F�C .ff D T/C� - �� rep semotives of this County 10 eNer opon the obove- � - - � - �� ToralFee � +�� �"/^'. y7 � . 'oned properfy for inspection purposes. - .�r,F�j��✓�✓ '�'( � . _ � � . . . . . . � , S�gn e of ApplimM ar Agent Doie � 3EE REVERSE FOR EXPLANATORY LANGUAGE- - - , , .► _ 2 q _ o. � r 1 'i ; . ' r �a�- '�. � � Q � � �- . • �. x =� r o :• o ti O � n ,• :%, b a n 9 pu� O � 2 � � �', (�i � �� �„ 9 �, 7 Z � � �' 1�; � .s '� t ,.. ^ m Z ` "� " �- � \ � � in Z+ } . {�; 2 � u� ' A .pm M � �o � • • p � N � � 2 i ` -' o p . G� _ '" 5 ,� �'y M c - ' 's� b . 'C Q N �a � � � r� i N �. ' . � � � i � O ` . � . 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