HomeMy WebLinkAbout1642A 4167A (9) , f �
wORKERS'COMPENSATION DECLARATION ; '� � �� -' ; �I � � � � ' _ �_�.1 f-�—'` �
�
1 hereby affirm that I have a certifitote of consen�'-to 1f � � �
insure,or a cErfifico�e of Worker$�, ensoµon��9�,a�:. ; �k,PPLICATI�N �QR COMBINA�'10N SWIMMING POOE PERMIT
ora certified copy thereof(Sec.3 l .} i � , i' �2oe i ..,.._.,. . ...... �......__., .. . -
. ......... ,,...._...____.,....... ._.. ._........___..,....
- Itea�s(i�iBtE
Policy No. Compo y COUNTY�OF LOS ANGELES BUIIDING AND SAFETY �`- '
��Certified copy is herebw; nish� �
O FOR APPLI TO FILI IN ewioiN� q:�Q
Cartified copy is fil with ihe counfy building inspec- ADDRE55 J(�--`Q� .�:��
tion de ariment BUII�ING g (J� - �
AD�RE55 vC�p� {.y�,e - LOCAIIN -
Dote Appliconf NFARES7
CERTIFICATE OF fXEAM1PT{ON FROM 1HORKERS' ��TY � � Z�P CRO5.5 Si.
COMPENSATION INSURANCE q �] 5ize OF ASSESSOR
7RAQ �/OU ! tOT LOT NO. � MAP BOOK PAGE PARCEI �
(Tbis saetion eaQd no!bo campiQlad ti!Iw pwndl 4s iw owQ � TEt. USE 2DNE MAa p .
huudr�d dollars(5100)or last.) OwNER . NO. � No. ��1 O ����
1 certify thot in the performance of the work for which ihis . . ��iqi I
permit i5 i55ued,1 shall not employ any person in any manner ADDRE55,�� L ' CONDITIONS
sa as�o become subjecf to the Wor�r5"Comper]g�lian t-'�jrs. � .� , �ISTRIC7 STATIS7ICAL CLA55 TYPE PROCESSEO BY
�7 �-7 /�'� �s�n.��I ���CIT � , ��� ZIP- � CONST.
Do�e�L_L;.-SZ-'�.—App�i�anf - -t i<Z���—'' ARCHITECTOR TEL. O ClA55N0. �
NOTICE TO APPLICANF: If, ofle. making this Certifimre of ENGINEER ��, � .,.i� NO.
Ezemption, you shovid become subject to the Worked O �� � VAtUAT10N �v
Compensation provisions of the tabor Coda,you�must£orth- A�oRe55
with tomply wifh such provisions or this permit shall be CONTRACTOR TO. s �C%.�d
� YAIiDAFiON
deemed revoked. /} - ' '
LICENSED CONTRACTORS DECLARkTION /' ���� a .;1 /: "
. ADDRESS��CO l ) NO. uZ �J �...i H
I hereby offirm thof I am licensed under prorisions of Chapte�9 � ��� /� j � �
(commencing with Seclion 7000)of Division 3 of the 8usiness GN CL' -� CLA55(���3 };• � ° ��� � }'"�
and Professions Code,ard my license is in full forca pnd effect. 6
L/� DESCRIPTION OF WORK F�� .� m o L'}�(�;i 0
Lice�se Number'ra� ��� Lic.Clqss .�S�� SWIMMING POOI ��� � p�h l��� 7 .�/ V
//�• / ,���7 ry � � �" �� � . :��':';V �
Contro[tor�N�/�j,�r+'�-���te ("�7�'l S SPA FINAL �
� 50.FT. ��o� .�� BY � �:.�`i`:;r' V
� I am exempt under Sec. -SIZE �
N �B.$D.C.far this reason ELECTRICAL z
Dote: � • /,� � , , .�
Steel 8 Conduit Bonding I��
$ignafure Conduits,Conductors,Equipment (f�
SINGIE FAMILY ti
HOME OWNER-BWI�ER DECIARATION PWMBING n ry��
1 hereby affirm thot I om exempt from the Contmctor's license � �C.v p ;J y� �
law for the following renson(Section 703I.5,Business and P_T�a `� "�` I -
Professions Code): Gas System �i` � ` �:C' C-r'�'i
� 1,os owner a f t he proper y,wf l l do�he p lom bing on d A n t i-Sy p h o n �S� l� r s . . c
elecfrical work.I,or my employees with woges as Iheir l
sole compenwtion,or a licensed wntrocfor will do all MECHANICAL L� �� � �- � � . . ,_
ofher work and the structure is nol intended or offered JG�'J �� _ _
for sole(Seclion 7044 88P Code). Swimming Poo�Heater ` `' . � •��:- .
CONSTRUCTIONLENDINGAGENCY v��J � ^; -
I hareby affirm lhat ihere is a cons�ruc�ion lending agency for � �� • � � � _�" '
APPLICANT 7fL.
the perfprmance of the w rk for which this permit is issaed (pRINT) Np.
(Sec 3047,Civ.C.}. �y / �
Lendei s Name �'v qpDRE55
Lender's Address �(�"' � - � � � �
P.0 Fee S � 0 Permit Fee Y.�v
i certify�hat 1 have reod this applimtion and state�hat ihe �
obore information is correcl.I agree to comply with all Counly 10�
ordinances and S�ale lows relating to building, elecirical, �ssu ceFee
mechonical and plum6ing construction.and hereby authorize I��es��yar�o�Fee �n l ��O
represenlativ f ihis County ro enier upon Ihe obove- Toml Fee/ � � '� - J �
men' ed ope�y for inspection purposes. - ,/� /J /jJ' i
,G �L�'-,-�-v__-�� d�ii-&.�.--F.�.r, �..�,u.v °
$ig�amre of Applkoni o�Agen� Oa�e SEE REVERSE FORiEXPLANATORY LANGUAGE Q,�' �. /J/�' '' �� , �" -� f
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