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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 . I . 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