HomeMy WebLinkAbout0973A 1142A (7) �,; .
� WORKERS'COMPENSATION DECLARATION !� ' � - [�
I here6y off„m thar I ha�e a certilitote o,conzenl fo seli ;. qpp��CATION FOR COMBINATION SWIMMING POOL PERMIT ��
inswe,or o cerlifitate of Workeri Compensation Insuronce, i'
o�o c d copy thereof(Sec.3800,(� 6/�.C.�)�} ',' 76n2oe
'���p y L�r.l�+W� .�CE816(3/eal. . ' ' , - ..
Potic a� COUNTY OP LOS ANGELES . BUILDING AND SAFETY
� CertiFied copy is hereby furnished �_/ �c/ -� � ' ,
�ertlfied co s filed with ih nt 'Idin ' � �' FOR APPLICANi TO FILL IN BURDING �r-7 /t l�
Py� y g inspec• � ADDRESS
�io deportment` � /'� ^' ' , � U
I AOORESS d�7 O ��y�l�� QV�•� ' LOfAUTY ,�
Date��Appli[ant ' m61�4-1 �!-1� NEAREST .
- � CERTIFICATE OF EXEMPTION FROM WORKE I qTY.1'�j( Z�P, . CRO55 ST.
COMPENSATION INSURANCE I TRAC4���v LOT O� LOT NO. • MAP560pK PAGE PARCEL
(Thi�sacfion nsed not b�eemplNad if th�p�rmif ti for one 1 / iEL -7 2 USE ZONE MAP (; '
hundred dollors(SI00)or 1���,) . OWNER f („�dD-1� NO. /7J . NO. �o}3J7
I certify thot in Ihe performance ef the work tor which this � ��� �/� y� ' SPECIAL.
permit is iss�ed,I sholl net employ ony person in any monner `. ADDRE55 (f"-�l�+� � �,yV 1�lJ CONDITIONS
5o as to become subjecf lo fhe Workers'Compensalion laws. I �.�{�/{� - DISTRICT STAi15T1�P.�C1A55 ' TYPE PROCESSED 6Y
. . - � CITY �YV��/}/ ZIP CONST.
Date Appliconl - . ARCH�TECT �'�� � �TEt. .!'D ��ASS NO. � ,
NOTICE TO APPLICANT: If, of�er moking this Cerlifimfe of ENGiNEER NO S�C�C�j � _
Exemprion, you shouid.become su6ject to rhe wo�►e�: ; Aooaes�b(lJ�O�/"�i'�/J v�tuATiON �
Compensot�on provisions of Ihe Lobor Code,you musf forth- s YAIIDATION ��`
wilh tomply wiih svch provisions or fhis permit shall be / TEL/';_ � � j '`,�` ��
deemed revoked. CONTRACT dpLS� NO.l � ��`.v
. LICENSED CONTRACTORS DECIARATION S LiC. O` ' - •
I hereby ofiirm Ihof I am licensed under provisions oi Chop�er 9 aDDRE , _�
(commencing with Section 7000)oi�ivision�of�he Business . ���� � . '
ond Profession e,ond my itense is in full forc � ffect. � ��TM v� CLA55 � � -� � i
/�/ DESCRIFTIONOFWORK ' ' ' ' '
license Nomber l.J Cc.Class��. HNAI � �� ► � �0 9 7.3�} '
SWIMMING POOL DATE �:
/� l ��,, �� � �-Cd�Sb g� n-
Con�ro�� �-U l�DolesL�_� � SPA F . {�e • • •`L� O .
❑ so.EFT. � - " I • •4 9.0 9 � .
.1 am eaempt vnder Sec.
6.8P.C.for this reoson � .�� EtECTRICAL- . _ _ . . . , • • °4.9,p 9�% O
'� �( � ... . . . W .
� Date: � D�1,�6�8� '
' Signoture S�eel 8 Conduit Bonding - 1 YI �
Condui�s,Conductors,Equipmen� [/'�
SINGtE FAMIIY i !'—� � � - Z .
HOME OWNER-BUILDER DECLARATION � p�UMBING � � . . "
I hereby afFirm�hol I om ezempt from ihe ConlroUor's license � � , . , , _
law for ihe following reason(SeUion 7031.5,Bosiness and p-Trap � . - � . -
Professons Code): : � .� 1 Gas Sysrem ' -
� I,as owner of the proper�y,wili do the�plvmbing�and Anti-Syphon � - ?� � Ii.C A ;
electritol work.I,or my employees wilh wagas as their �
sale compensolion,or o licensed conlraclor will do oll MECHANICAL � - ' -- � � � � � ii° • • • •.3
olher work and the siructure is not in�ended or offered `
' ior sale(Seclion 7044 88P Code). � -' �' ' �Swimming Pool Hea�er � " ' �Lfy�yI � • � 7��J n
CONSTRUCTION LEN�ING AGENCY �\ ( � • � %�.J�`
I hereby oHirm ihat ihere is o construciion lending ogency for AP7lICANT V
the performonce of ihe work for wh�ch ihis permi�is issued �PRiM) ' �7��2„�b,5
-(Sec.3097,Civ.C.�. . ` � ,
lender's Nome ��� aDDRES L �.- `z e_. ��� . .. . . .. . .. .
Lender's Address �,� . � .
P.C.Fee E � •� Permif Fee • - �
I certify that 1 hove reod ihis opplicofon and state�ha�ihe - - �
obove inlorma�ion is correct I agree to comply with all County - . ._ ' ' . � �
ordinonces and S�afe laws relo�ing �0 6uilding, electricol, IssuanceFea Q���
me "al and plum ing constroction,ond here6y authorize'`� ���esr�gation Fee �J ^ �. , . _ . �¢
resenta es of.lFis ounly to enler upon Ihe obove- � � ToMI Fee J .J V . . �
r eNioned p� rry for� spection purposes. , � � . . /
4��`���� .
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