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HomeMy WebLinkAbout0994A 1366A �/ ,� /� WORKERS'COMPE VSATION DECLARATION r" '-��1� -�I �.. I hereby affi�n.that I,ha• a certifi�o�e of consent to self �I ' ,�s�,a,ar a ce�tificatr of arkers'Compensation��S��a��e, APPLICATt4N FOR COMBINATION SWIMMING PO�L PERMIT �� � or o cerfified copy tka.•.� (Sec.3800,L b.C.) 76nzoe ' + CE816�8!B4� � Policy No.�Compony - COUNTY OF LOS ANGELES BUILDING ANO SAFETY � ertified cop�is here6y furnished. . � FOR APPLICANT TO F�LI IN euuanw Certified copy is filed wifh the counfy build�ng inspec- ADDRE55 tio�departmenl. BUILDING AD�RE55 LOCALITY poi¢��_Applicant NEARE57 CITY ZIP CRO55 ST. � CERTiFICATE OF EXEMPT�ON fROM WORKERS` S�ZE OF ASSESSOa COMPENSATION INSl1RANCE iRACT �O iOT tO7 NO. S MnP BOOK vnGE PARCH (Thl�s�clion nvod not bu complNed tF tM psrmil is for on� TEL.p� ��j USE ZONE MAP � � hV1lEnad IIOIIaFi(SIOO)W�YN.� � OWNER NO.O ��/L NO. I certify�hat in the performonce nf fhe work fw which this - SPEpA[ , permif is isSVed,t shali not employ ony parson in any manner ADDRE55 - �CONDITIONS . so as to become subject fo the Workers'Compensation Lows. -� � � �� � � DISrRICf STATI$TICAI QA55 TVPE PRIX'lSSED BY � ._ - .�. CI7Y ZIP '� CANST ! �ate APP�i[ant ARCHIIECTOR TEL./ . .1� �SS NO.�;._. .. . ' NOTICE TO APPLICANT: If, aEter moking this Ces�ificote of ENGINEER NO�J,3 � E.emption, you should become subjecF lo ihe Workers' ��E� - � �, VAIUAiION �'� �� .. . � . � Compensotion provisions of the Lobor Code,you most forth- , � �:� ; yp��pqi�qN . . k with comply with such provisions cr this permit s!i_all 6e �. ..-... __.. _.- .. . TEL. P� s 1` Q Q, deemed revoked. CON[RACTOR NO.�[�� �l � � LICENSED CONTRACTORS DECLARATION � ���' t-n ADDRESS Na��JV Z I hereby affirm iha�1 am ficensed under provivons of Chop�er 9 ��� f _, �. (mmmencing with Section 700p)af�ivision 3 of 1he Business ��Ty C�q� �����- � •� , c,G C�'Q(j f{ ond Profeuions Code,and my license is in fulf force and effect. ��R����WORK �j{ � � )�� C �` , FINAL t !*• • � �C� �.Cice�se Number�L-YJ Lic Class✓� SWIMMING POOL L� DAtE � p� �� � a . . -•_ �.���. ..SPA._.. ._._.._ ..... FINAI � 49.09 Q. Fonhoclor [ h��. Date �.Ft. .Y �/� / � � s�ze '�"' c:%,G G� � I am exempf under Sec. - - ^� �� � 8.8P.C.forthisreoso� . . � t`�y ��`]��. . .. - �u�/j�•-R7 ... v _ �EIECiRtCAL J ♦�. c Dafe: �j W . Steel 8 Conduil Banding � . {_.�j- n L` p.�� - . � d � Signoiure Conduits,Conductors,Equipment L.J �O�-� O z � SINGLE FAMI�Y . - — `- HOME OWNER-BUIL�ER DECLARATION PIUMBING �� �ere";affirm�hat I om exempt from fhe Controc�or's License , � . - . � iw I �he following reoson(Section 7031.5,8usiness and p-Trop � � �ofess ns Code): Gas Syslem �Q,y�� - � � � -�s owner of tha property,will dv the plumbing pnd Anti-Syphon elechical work.I,or my employeas with woges as Iheir � solt compensotion,or a licensed tontroctor will do oll MECHANICAL ^—" - �' othe work ond the shucfure is not intended or offered � � ,, � -- , . � a '��.far sale(Section 70d4 B&7 Code�. .. .... . . " . . Swimming Pool Heofer .. . . - � .-....�... �"".'-� - .�•.°'..:". . z�'�.� �-A--. . ^ CONSTRUCiION LENDING AGENCY � ._. ....__... - ' p�+���3 I hereby aftirn..jhot there is o construciion lending agenty for � . the performance'�f the work for which this permi�is issued A�pRry� . � p�p. � � � � •�7��.�J Q �Seo 3W7,Civ.C.i tender's Name � � � � ��'��`� ADDRESS �� r � �y O�_�� lendei s Address `� o O P.C.Fee 5 � Q Permir fee . I certify thot I have reod this applico�ion and state Ihot ihe , a6ove informa��on is corretl.I agree fo comply with oll CouNy Issu ce Fee , Q� � � ordinonces and 9ate laws relating to 6uilding, electricol, °" mechaniml ond plumbing mnsiruction,and hereby authorize Invesi�gation Fae � . repr alives af this Counly to enter upon 7he above- 7otal Fee � ���o�a rope i peclion pu�poses. 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