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.
I O [�Y'� / I
atu e of ApplimN or AgeN oo�e� SFE REVEYSE FOR EXPLANATOYY LANGUAGE
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