HomeMy WebLinkAbout1603A 2058A WORKERS'COMPENSAiION DECLARATION � �, �
I hereby affirm that I hove a cerlificole ot�o�5a�,�o self �APPLiCATION FOR COMBINAT{ON SWIMMING POOL PERMIT
insure,or o certificate of Workars'Compeosation Insuronce,
or a certified copy�hereopf Sec.3800,La .C.) •'6a2o9
����j�0[?�(fs"'3o�7 � CE876�3l84j
Po iCy No. Company GOUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cenifiad copy is hereby P�mished.
Q FOR APPLICANT TO FILL IN swioiN�
Cu}ified ropy is f led wi+h the rounty building inspeo- ADDRESS Q 3
tion deportment. BUILDING
�[/_� ADDRE55 LOCALITY �.
•/�t�ole Applicant NEAREST �r' /J� �,`
� CITY ZIP CROS5 57. J {"r" •G N
CERTIFICATE OF EXEMMION FROM WORKfRS' SIZE O ASSESSOR
COMPENSATION INSURANCE TRACi � LOT l0T NO. MAP BOOK PAGE PARCEL
(Thi�:�dion need not b�compiNed if 1ho permlt is For ono �. ���D N µqp v �
h�ndrod dolbn(St00)or I��e.) owrvER �/ /�"� No.. ��O^3�
i cerliFy thai in�the performonce of�the work for which�his 9�OQ�� 57EClAL
permit is issued,I shall not employ any person in ony manner AD�RESS O CONDITIONS
so as tn become subjec�to the Workers'Compenwlion Lows. - o�SrRiC7 S7ATISTiUL CLA55 TYPE PROCESSED BY
CITY �'� Z�P I� ��S� CONST.
Da1e Appliconl ARCH1TECi OR 7E1. ld
NOTICE TO APPLICANT: If, ofter making this Certifimte of ENGINFER NO. ' �� �
Exemption, yoU should become sobject to the Workers vALWTWN
Compenmiion provisions of�he Lobor Code,you must forth- ADDRESS VAIIDATION
with comply with wch provisiom or ehis permit aholl be �TRAROR NLTiJN •TNO '/ ; /� �
deemed revoked.
LICENSED CONTRACTORS DECLARATION UC.
AD�RESS tdO_
l hereby affirm ihol I am licensed under provisions of Chapter 9 ��� f
(cammencing wi�h Section 7000)of Qivision 3 of the Bvsineu ��Ty ��q�
ond Professfons Ca1e,and my license is in full fwce and effect DESCRIPTION OF WORK �
"""� z160,3A
icense Number j9��Lia C�ass� SWIMMING POOL � DA7E
� ^ r
A �(f(} � a��•�' S SPA LJ FINA} �• • • •C 1 a
Contractor N'^"� �-�8ate� V �
�O.EFT. 6Y I • �6 I�O H �
4 om exempt unde�Sec. � .,_
&.BP.C.{or thie reuson ' � • a g� r.C;;,�; �
EIECTRICAI ',�I V
�ote: '�f'v� ���� 0?.L3-85 W
Sleel 8 Conduit Bonding ����� _,. �'
Signature Conduits,Conduc�ors,Equipmenl 2 z
SINGLE PAMILY �1� 7�7 —
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby eftirm that I am exempt from the Coatra0or's License � �
Low for the foilowing reason(Sec�ion 7431.5, Business and P T�aP .
Professions Code�: Gas System
� I,as owner of the property,will da the pl�mbing and A�fi-SYPho� � _ � ' �;L��3 t�i p
eleUrical work.I,or my employees wifh wages os fheir ,�'"fl^-�"�
sole compensation,or a licensed contrpdor will do all MECHANICAL o � �?•�r • • •3
other work vnd the strucrure is noe in�ended or offered
foi sale(Section 7044 B8P Code). Swimming Pool Hea+er � � •L 3 a,Q Q
CONSTRUCTION IENDING AGENCY • •2 3&0 G u
1 he�eby affirm thor there is a consfruUion lending agency for _ APRIG4NT 7EL. �
ihe performonce of 1he work for which this permil is issued �pR�NSj NO, � Q 8 O 7+�8 rj
(Sec.3097,Civ.C.).
Lender's Nome ADDRE55
Lender's Address / '� �-y�
� P.C.Fee E `''���� Permil Fee � �•� v
I certify ihat I have read this application ond state that fhe �
above information is correU.I agree�o mmply with ol)Counry �0 .��v
ordinonces and Sfole laws relating lo building electrical, Issuance Fee
mechanimV ond plumbing consfruc�ion.Ond hereby authorize � ��vestigation Fee � ? p� O d !
representotives of this Couniy �a enter �pon the above- toml Fee Q�'•� �
menf�oPerty For� speclion purposes.
/ q�or��e o p o� or Agent �!� SEE REVERSE FOR EXVLANATORY IANGUAGE
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