HomeMy WebLinkAbout1603A 2058A (9) WORKERS'COMPENSAiION DECLARATION � �, �
I hereby affirm that I have a cer�if�ca�e ot�o�5a�,�o ge�+ � —APPLICATION FOR COMBINAT{ON SWIMMING POOL PERMIT
insure,or o certificate of Workars'Compeosation Insuronce,
or a certified copy�hereof Sec.3B00,La .C.) •'6a2o9
����j�0[?�(fs'3��7 � CE876�3l84j
Po iCy No. Company GOUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cenified copy is hereby f�rnished.
Q FOR APPLICANT TO FILL IN swioiN�
Certified ropy is f�led with the rounty building inspeo- ADDRESS Q 3
tion department. BUILDING
�//_� ADDRE55 LOCALITY �.
•/�t�ole Applicant NEAREST �r' /J� �,`
� CITY ZIP CROSS 57. J {"r" •G N
CERTIFICATE OF EXEMMION FROM WORKERS' SIZE O ASSESSOR
COMPENSATION INSURANCE TRACi � LOT l0T NO. MAP e00�c PAGE PARCEI
(Thi�s�dion need not b�complNed ii tho permlf fs For orw l, USE}�NF� MAP �{ v 7
h�ndrod dollon(St00)or I�se.) OWNER �� /L'/ NO.. /v Q^3/-
1 cerlify that in�the performonce of�fhe work for which�his 9�OQ�� 57EClAL
permit is issued,I shall not employ any person in ony manne� AD�RESS O CONDITIONS
so as tn become subjec�to tbe Workers'Compenwlion Lows. - DISrRiCr S7ATISTiUL CLA55 7YPE PROCESSED BY
CITY �'� ZIP {I C�S�. CONST.
Da1e ApplicoN ARCHITEC7OR 7EL. ld
NOTICE TO APPLICANT: If, ofter making ihis Certifimte of ENGINFER NO. ' �� �
Exemption, you should become s�bject to the Workers VALWTION
Compenw�ion provisions of�he Labor Code,you must forth- ADDRESS VAIIDATION
with comply with such provisions or ehis permit sholl be �TRAROR NLTiJN •TNO '/ ; �� �
deemed revoked.
LICENSED CONTRACTORS DECLARATION LiC.
AD�RESS tdO�
l hereby affirm ihot I am licensed under provisions of Chapter 9 ��� f
(cammencing wi�h Section 7000)of Oivision 3 of the Bvsi�ess ��Ty C�q�
ond Professfons Code,and my license is in full fwce and effecL DESCRIPTION OF WORK �
"""� z160,3A
icense Number��_Lic.C�ass� SWIMMING POOL � DA7E
� r
A �(f(} � a�� S SPA � FINA} �• • • •C 1 a
Comractor �'^"� �ate� V �
SO.EFT. 6Y I • �6 I�O H �
4 om exempt unde�Sec. � .,_
&.BP.C.{or this reusan � � • a Q� i.C;;,�; �
EIECTRICAL ',�I V
�ote: -�p v! ���� 0?.L 3—8 5 u�
Sleel 8 Conduit Bonding ����� _,. �'
Signature Conduits,Conduc�ors,Equipmen� 2 z
SINGLE PAMILY �1� 7�7 —
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby effirm that I am e:empt from the Coatratlor's License � �
Low for the following reason(Sec�ion 7431.5, Business and p-Trap -
Professions Code�� Gos Sys�em
� I,as owner of the property,will da the pl�mbing and Anti-Syphon �[,� G L���4 A
eleUrical work.I,or my emplayees wifh wages os fheir Lf'
sole compensation,or a licensed contrador will do all MECHANICAL � ��!•�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 thar there is a construUion lending agency for _ qpRIG4NT 7EL. �
ihe performonce of the work for which t6is permit is issued �p{21NT) NO, � Q 8 0 7+�8 rj
(Sec.3097,Civ.C.).
Lender's Nome ADDRE55
Lender's Address / � �-y�
� P.C.Fee E `''���� Permil Fee � �•� v
I certify that I have read this applimtion ond state that fhe �
above in{ormation is correU.I ogree�o mmply with a0 Counry �� .��v
ordinonces and Sfole laws relating lo building eleclrical, Issuance Fee
mechaniml ond plumbing consfruction,and hereby authorize � �^�estigation Fee � p, O d ;
representotives of this Counry �o enter �pon the above- toml Fee �
menti ed property for i speclion purposes.
/ q�or��e o p o� or Agent �!� SEE REVERSE FOR EXVLANATORY IANGUAGE I
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