HomeMy WebLinkAbout0995A 2558 (5) WORKERS'COMPENSATION DECLARATION - � -- ' �•�! ����. � � . .
I hareby�ffirm thal I have a certificote of wnseM to self ` �
insura,or a cer�ifimle of Worken'Compensarion��,�,o��e, APpLiCAT10N FOR COMBINATION SWIMMIN - POOL PERMIT � 1
'or a certified copy thereof(Sec.3600 Lab.C.) ]6A208 .
f CE878(3/B4)
Policy No. Company ~ CDUNTY OF LOS ANGELES BUICDING AND SAFETY I
� Certified copy is hereby fumished. ' - �
�-7� fOR APPLICANT TO FILL IN sui�oir� !
y� Certiffed copy is filed wilh ihe county building inspac- � � qppRE55
/`—� lion deparimenf. BU�I�ING
��(�.�� ADDRESS ' I� LOCALITY
Date_e��J.�L1.SApplicant n NEAREST ._ _ .
cQosssT. G�. 73KociLwo�
CERTIFICATE OF EXEMPTION FROM WORKERS' � ��TM Z�P K'
COMPENSATION INSURANCE 7 S�ZE� Y ASSESSOR . �
iRAQ 4 S�D LOT LOT NO. MAP BDpK PAGE PARCEI
(Thi�uc/ion�d nof b�compief�d if the p�rmil Is ior one � . � � .
hundrod dollan(SIDO)or lasc.) OWNER ' Np' USE ZONE �. ` 4 �
�certify Ihot in 1he performonce of the work for which this - '• SPECIAL
permif is issued,I sholl not employ any person in ony monner ADDRESS {� ' � � °� CONOITIONS � �
so as to become subjec�to the Workers'Compensotion Lows. DISTRICT �S7ATISi7CAL f1A55 TVPE PROCESSED BY �
CITY Z!P '� CONST.C�
Date Applicant ARCHi7ECT 7Et. � ,� �w��' �` _ "
NOTICE TO APPLICANT: If, of�er making ihis Certificaie of ENGINEER NO. C37—'�
Exemption, you should bemme subject to fhe Workers' yALUATION
Compe�sation provisions of Ihe La6or Code.you must foAh- /DDRE55
with mmply wilh such provisions or this permit shalt be TEL s ,O VALIDATION
deemed revoked. CONTRACTOR NO. � �
� LICENSED CONTRACTORS DECLARATION ��� �
� 1 here6y aFfirm�ho�I am licensed under pro�is�ons of Chapter 9 Aoo3E55 NO. : - '
(commencing w�th Section 7000)of Dir�sion 3 of the Business ���� �
ond Peofessions Code.and my license is in full force and effect. Ciiv . Ctn55 �
��V C.�! 53 DESCRIPTION OF WORK � �G CJ CJ,�A
License Number Lia Class � F�� � f� �
( �,�f DAIE wr � . � �� ••� a I
SWIMMING POOL
Conhtictor.�w�tJ(/l�a-- Date � �/'i�/ SPA l_J FIHAI � . � ' ti• •�e •�� U �
❑ SQ.FL eY
1 om exempf under Sec SIZE / � �
8.&F.C.4or this reason ELECTRICAt c�(� ��� - �' 0 4��g �
J\`.,� �•o aµC*I"�.fy�T V
Date: �y(
- Sreel 8 Conduit Bonding � � �g b�.. C�`4 y&,� p_ �
Signature Conduits,Conductors,Equipment �
SINGtE iAMILY . Z
HOME OWNER-BUIL�ER DECLARATION PLUMBWG � -- ��-` .
1 here6y affirm tha�I om exempf from ihe Conlmctor's liwnse . . - _ �
law for the following reason(Section 7031.5, Business and P_T�aP � �� `
Grofessions Code)� ' Gas Sysrem � ��� ' . -
� I,as owner of the p�operty,will do the plumbing ond Anti-$yphon ���
electrical work.I,or my employees with wages as�heir �� ���^
sole compensation,or a licensed controctor wilJ do all MECHANICAL p
other work ond the shucNre is nof intended or offered � .
for sale(Section 7044 B8P Code). Swimming Pool Heater
CONSTRLICTION LEN�ING AGENCY � ��^ F�}�
ri �{
I hereby affirm that there is a constroction lending ogency for ��� �*��D o
�he performance of the work for whith ihis permit is issued APP�pRIM TEL. .
(Sec.3097.Civ.C.). ( � / �� � 3
lender's Name A�DRE55 �i \./ -� � �
Lender's Address Q , ,��i��
P.0 Fee f ` .� Permi�Fee �-,
I certify thal I hove read this applicotion ond sta�e Ihot 1he � I �
a6ove informotion is correcf.I agree io comply with all Counly � , `Q''� �
ordinon�es and Stofe lows relating to building, elecirical, Issuance Fee �
mechonical and plumbing mnstruction,and here6y outhorize �nvestiga�ion fee _
e re nrarives of rhis County io enrer upon the a6ove- ioroi Fee
m Nion ed p� ry r inspec��on purposes.
�L�/--5� �
S�g orure of nppliwn�or qgeni Daie SEE REVERSE FOR E%PLA.NATORY LANGl1AGF .
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