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- - - , ,
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