HomeMy WebLinkAbout0973A 1142A (9) 17 �
� WORKERS'COMPENSATION DECLARATION !� � �
I hereby off��m �ha��ha�e a certilitole o,consenl fo seli ;. APPLICATION FOR COMBINATION SWIMMING PO4t PERMIT
inswe,or o cerli(itate of Workers'Compensation Insuronce, !'
or o c d copy thereof(Sec.3800, 6.C.) _ ',' 76pZoe � � � - - ��
(j��y1�, j' .�CE8�6�3(L'3).
votfc !_� '�L�`�pa�v " �P_,—.��x3�—�--`� .. . COUNTY OP LOS ANGELES . BUILDING AND SAFETY � �
� Certified copy is hereby furnished. f� /l
� �' BURDWG
err�fied copy�s flled with�h nty 'Idi�g�nspec• _ FOR APPLICANi TO FILL IN ADDRESS �� lJ 11�
tio deportment! , BUILDING /���JO C�' �-yn /tiU 1•. \ LOfAtITY .�
AOORE55 O� � JrVv/i-� �,1' '�./
Date ApplimM li {� Q NEnRESi
- � CERTIFICATE OF EXEMPTION FROM WORKE ��TY' � m'6�Q V�T'-' Z�P' . CRO55 ST.
I 512E OP ASSESSOR
COMPENSAT�ON INSURANCE Tqp�YV �pT LOT NO. • MAv BOOK PAGE PARCEL
(Thi�socfioe nsed not b�eempldad if th�p�rmif ti fo�on� i / ieL 2 USE ZONE M/P ��-3�7 � �
hundr�d doliors(5100)er La�.) . OwnIER f C..d�� NO. ��J � NO.
I certify tho�in Ihe performance ef thn work tor which this � (�n� �/� y-� " � . SPECIAL. . � � '�
permit is iss�ed,I sholl noi employ ony penon in any monner ` ADDRESS (i�"V��� ` C.l l.�i N CONDITIONS
sa as to become subject�o�he Worke�s'Compensa�ion laws. I ^��{I!f1 DISTRICT STAi15TICAt C1A55 ' TYPE PROCESSED 6Y
� cirr /\rv��Y Z�P CONST.
. D CIASS NO. /
Date Applicanl - . ARCH�TECT J..�'�i� NO S�G�C�r..� � � � �
NOTtCE TO APPUCANT: If, after moking this Cerlificate of ENGiNEER '
E�empHon, you shouid.become su6ject to rhe Wo�kers' ; AD�RES�b(v�LY� G"� V�wATiON .
Compe�sofion provisions of Ihe lobor Code,you musf forth- � TE�� � � � ���� YAUDATtON
wilh tomply wiih svch provisions or fhis permit shall be s `
deemed revoked. CONTRACT QD S NO. _ �
LICENSED CONTRACTOR$DECIARATION ���' -
ADDRE S �� s�
I hereby ofiirm Ihof I am licensed under provisions oi Chop�er 9 ���. C
(commencing with Secfion 7000j of 6ivision 9 of the Business ��n. � (f,� CLA55 . � . .
ond Pro�ession e,ond my i[ense is in full forc � ffect. DESCRIFTION OF WORK
1/`r �Q �'j1 NNAI y , � �097.3R
license Nomber `�+ l�c.CIoSs��L�.L SWIMMING POOL DATE � �.7 " . ?�.
.�r, ,� /� `` �S .� $PA �"CQ o��o�� � . F . �• • • •`�� 0 .
Con�roR���'-� `'�`1Dn�e '. �.FT. [� � e . . 1 • •4 9.0 9 .
� .1 am exempt vnder Sec. � S�2E v�' � • e A.9,0 9` t�— �
� 8.8P.C.for this reasan �.�; EtECTR1CAl- - � - - � � ' �• � W �
Date: �-y� � -.. . . . D�12�]�8� ' 0.
Steel 8 Condo�t Bondiog - }y�.� � � (A
' Signatvre � Condui�s,Conductors,Equipmenl �_,J � � " Z .
SINGIE FAMIIY . . � '
HOME OWNER-BUILDER�ECLARATION - } p�UMBING � ' . , . , . .
I hereby afFirm�hal I om ezempt from ihe ConlroUor's license �__ . T _
taw(or ihe lollowing reason(SeUfon 7031.5,Bosiness and r P-Tra . .
Profess�ons Code): : � .� 1 Gos 5 �em - � �
r� _ �114.2A
� I,as owner of the proper�y,wili do the plvmbing�and � Anti-Syphon • . '
electritol work.I,or my employees wi�h wagas m their , _ . - �i• • •.3
sole compenso�ion,or a licensed connac�or will do all �-MfCHANtCAL ` �
alher work ond ihe siruUure is not in�ended or offered � ��� � ' ' � � � • � �]�rj n
' for sale{Seuion 7044 88P Code). ' -' �Swimming Pool Hea�er
CONSTRUCTION LENDING AGENCY \ , • � 1 J.Fi O u
1 hereby offirm thoi therr,is o construc�ion lending ogency for App���qNT , � ' '
the performonce of ihe work for wh�ch�his permi�is issued (pRIM) � O Z O 2"'b'rJ
-(Sec.9097.Civ.G{. ,�,,,// - ` . .. . . .. .
tender's Nome • ��~ aDDRES � �-- 2� ��l _ .. . .
Lender's Address P.C.Fee E � •� Permii Fee ��.� ' � � - .
I certify ihai 1 have reod ihts opplicofon and state Iho1 ihe � � � � ' I
obove inlorma�ion is correct I agree to comply with all County - - � -- � - Issuance Fee Q��� .
ordinonces and$ta!e laws relating to building, eledritol, . , . _ . s
me -al and plum �ng constrodion,ond here6y authorize'`� ��°esr�gation Fee � . `a '
resenta es of.l�i�s ounly lo enler upon Ihe a6ove- ioMl Fee V � . . �
r eNioned p� rry for� spection purposes. , � , � /
CE,�:t��.� �
5� o���e o�n p�i�onl or A oaie . � SEE REVERSE FOR EXPLANATORY LANGUAGE �
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