HomeMy WebLinkAbout1048A 1111A (7) WORKERS'COMPENSATION DECLARATION '
I hereby affirm that I have o certificot�e of consent lo self APPIICATION �QR COMBINATION SWIMMING POOL PERMIT �
insure,or a certificate of Workers'Com ensation Insurance,
or�a Fer�afied c�oLpy thereof(Sec.3800,Lab.C.} y. 76A20B
W�O�� i a.�j� �Al..w..�w• CE-B75(l I/61). . .
Poticy No. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is hereby furnished. �� �_
O FOR APPtICANT TO FILL IN BWIDMG a U O S Q'
Certified copy is filed wifh the county 6uilding inspeo- A��RE55
tion department. � BUILDING
ao�Ress 2 o y�S /1 w�-r,rr ��H�ff �ocauTv (Q iYL
Date Applicant NEAREST l
CERTIFICATE OF EXEMPTION FROM WORKERS' C�iv �� /'�Q. 21P CRO55 5T. t.z�
COMPENSATION INSURANCE TRA� s��f� SIZE OF ASSESSOR
l0T LOT NO. �J MAP BOpK PA PARCEL
(ihi�socfion nwd not ba wmplafad if tha pormif is for ona hi. U pNE N„qp
6��a,�a a��b..�s�oo�o,�....> OWNER �f.3,�rs�� No. �. �/� - 3
t certify ihai in�he perfwmance of rhe work for which ihis y p [�U SPECIAL '
p@rmit is issued,I sholl not employ any person in any manner AD�RESS �`�.S �°"����"r /���'� �" COMDiilONS
so as to become subjeci to ihe Workers'Compensa�ion Laws. �ISTRICf STATISTICAt QA55 TYPE PROCFSSED BY
CITY �`BI��- ZIP CONST. ��'///111 //�
Date Applicanf ARCHITECT OR � TEL ��� %� C��. �' /)�! ,�
NOTICE TO APPLICANT: If, after making ihis Certificote of ENGINEER �a NO. o � r 4l
Exemption, you should 6ecome subject �o the Workers' VAIUATION �
Campensafion provisions ot the CpbOr Code,you�musi farth- A�DRESS
/ / `` VALIDATION
with comply with such provisions or �his perm"rt shal! be ��TRACTOR �yL"t� �`�t' TNO 4�7 spy s `=� �U V
deemed revoked.
LICENSEO CONFRARORS DECLARATION �( p /� � A����' p
1 hareby affirm Ihot I am ticensed�nder provisions of Chapter 9 '°'�ORE55 7��tl /c���f��-rr�0. �a s��L f
(tommencing with Section 7000)of Division 3 of the Business �p ttC.
aTv cvss C_�S 3 �
and Profeuions Code,and my license is in full force and effect. d
Oe� �^ OESCRIPfION OF WORK F{NAL � � O
LicenseNumber �+✓�A LicClass C`� SWIMMWGPOOL ppTE ,{�:.,��^�' u
Confrocfor ���� �'� Dats - �A � FINAL � -
so.FT. ev
� I om exempt under Sec. SIZE ��� �,� O�8 A y
B.&P.C.for ihis reason ELECTRICAL � -#���� �2,� z
Date:
Steel 8 Conduit Bonding . . � • •6�9 7 �
Sigrwture Condui�s,ConduUors,Equipment
SINGIE fAMILY � ' • • �6,Z„9 7�
HOME OWNER-BUILDER�ECIARATION PLUMBING � �� �
I hereby affirm that I am exempt from the Controctw's license � , -- � � ' 0�•� b�'8.� �
Law for ihe following reason(Section 7031.5, Business and p-Trap
Professions Code): � � � Gas System �
� I,as owner of the properry,will do ihe plumbing and Anti-Syphon
elecNical work.I,or my employees with woges as their
sole compensation,or o licensed contraUor w"ill do all MECHANICAL .
other work and the structure is�ot in�ended vr offered � z 1 1 1,1 A
for sale(Section 7044 88P Code). Swimming Pool Healer � ��
CONSiRUCTION LENDING AGENCY 3 3 3 O� ,�T�+'- #• • �3
1 hereby affirm�hat there is a construc�ion lending agency for A���NT TE� � •2 2 5,j Q I
the performante of the work for which this permit is issued PRIM NO.
�se�.3oa�,c��.c.�. � � � ...�2`a 5 0=
U �
tender's Nome A�DRESS 0 1,�0—8 4
' Lender's Address q I
P.C.Fee E '�, [ Permii Fee ! � �u
I certify ihot i have read this applica�ion ond state�hat�he � �
obove informalion is mrrecL I agree ro comply with all County � �(�. 5(�
ordinances and Srare laws relating to building, electrical, � Issuance Fee
methan' I and plombing tonstrudion,and hereby oulhorize Investigotion Fee , �U
repre nl tives of this ounty �o enter upon the above- Toml Fee o1 S
men on d p r for pection purposes. �
/—l6 g�
' n ure of Applimnt or Agem � Date SEE REVERSE FOR @%PIANATORY LANGUAGF . � �
� ,� 4i 0 Cl � V U �� � « � � I
� �?V N d �L � �" �in O�� � . �� 4 N O .O �_ C�` G: O ��.- I
'aM:c - ` o 3o� .yQ� �3 ao ��_ � o L o .o� a` � o �
�a3a � �o � mo c �n � u�L cmo �. Qco.,, a
° � a � a� � �a+ `^ a+_c a°'i o � �.�n E � »� o m � y u a� � U i
o � �v c o c cv o� m o 3�n-� o:'c 3s o 'n� m e � a I
a o�'„ h� o-c o � �c ° o a
Z a� °u � � ' 'S E � o c u ' �.L°' v 3�+ o'3 a � ;,'' y "-o °a �
Os � oaaoE ;nEom � � oo >, o -o E x � m � oa m
-. c ° ` r�' ii p a � o ° � 3� �+ � � � ti 3't '^ I i
� o o '� � N o m ."..��o N� E��V o j a r' ����° o o U° c v � W i , f
� - - �
Q .� m > • - �a m d '> .� y 5 '3 m m a� o o m� .� ` o � o o N ` O ' i i ` �
-� c d "- " � y� > o �.c E .n o I i � I i
iV o- m Q o E m� c y E � c �-o w a ° > `m v '" � >, c:: f Z !
o y ,= d ° � v o o aQ a d °o ti �v° �v o c � •� o� ,�v ° . en i I . ,
x 3-a � o a�s o E o o a o o�a c m m a 3� u a� u m � m ; � ' I
p ° ° u � a� '`� � °� � a m�v o-� '' � E w� �; � a �-� � � m c t�-i � � ! I
� a � o p a v p o � �� �.. � E c o o v o.� o'c'c = °c y � o m � 3 u, ; ! i � �
m .L V "' ' � >S W U p O � n O C C� G� - O O'P 0 N � O G � I N I
� o _ '" o u c w x • � o c ., a a� `o � c� c� � o � °; Q � Z f I � I
w « a' ., � o u c(] p d a�, a� • ti a. � � c''a o � `y �. a�° a;� � � - �
Z � o a E „ �- ?;o�� a 4^ 3 ° N ° �� D d� a� c�; 3 � � o � 3` X ;
H . d a o a"a o- � � � a, I �.
3 �, m �`ati'�,-•o o � �>o o '�, • -o d y � o y s �, � a � a f , ;
� oocaoo.c`o� o "� o� � ac"�� '"� oa.� o = `v �� .°V' O a ' , i �
� � L � O 1�� � �. O 4�l . N � N N y ' O � ` S C' Gl , O - I 1 � ! i I
W v Q' v GL L � O V L 'n � �❑ O � v a O � N N � N O❑ c I� ��,�p a O � C � . ' . I
- G_ 0 m '^ � 6 v v� C � � � u � f ' I .
�, � •N �� � � c � � � � e °i . 3uo 'o3ova � �� L� � �;. .
t u � a b o v o 0 0 0 o a L � J E� o m,> > o ,n o N r ° o I I � I� I
�m o �E U in � r� u b 3 m . 2.c >.-a u.. � 3 a p . ,
� I "'
s
� .. �
Q .. '
N I
� i �
� r �
v I I
W
6.
H
Z
i
. � I
I
• ' � ,
, I .
9 �
m .
>
O
�
a O �
a
4 u �
: z �.., I
_ �� ;�
; � �
. :
u c o . f I .......0 i �
¢ o
�
� a - - - � --- — - i �
� , ..�
Q O0 � w � ��,
O � I Q � I � i i ��
r p . �
2 - � �i .. - .�
� , ` � -------_ � -.. -- ---'r-��-- ' ---�--�---i :
�G l I I !� • ; ��
a E j � : i � ' -- � I � I
t ; I I I�z > ! ;
` d � i z . � � l�= �a �
I ! j io� • Z � �
i E o � � I i ° � � j ' � _ � a ��; j � o w
i . � i j l~l �n.1 �- ' ! i n •> W ..r- �".� Z V � Q F Q .
� : i - j �., � � . : I _ Z a x !u�w � a V �n �
j . i D.. � C � � Y! : . � Rf �N� R''. 1-� � W Z
i � i : � Z 0 � „ ; � � � � � . . .� V X ' . �. W ; � ° W � '
1 I � O � V 2 . ! 7 � C G � -.- I N � I A � = W ? � O. I
i �`J �I Q W = 1 � ' z N Q � } I ( ~ W ° Z Q � ya! Q 1 Q F' !
. u
� , ~' Z �� — O � �_J�m_f'—-'"_V_�s�N�—I_'__�"_a'_'� �` (� OC - _ x U' Li d I
-------�— ----��-----`-`--'--�'--�-'-- �-'-- �-------�