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HomeMy WebLinkAbout1089A 2559A ' WORKERS'COMPENSATION DECLARA710N , - � � N!! �`�. . . . . I herekty�('{firm�hat I bove o certifim�e of conseM to self � � o�a�cert fied copy�hereofy($e�e3��a e^�;���Inwrpnce, 78A2�B AppLICATfON FOR COMBINATION SWlMMlNG P4Q1 PERMlT u L CE876(3!Ba� Policy No.-�I�Company COUNTY OF LOS ANGELE$ BUILDING AND SAFETY � Cenified copy is hereby furnished. FOR APPUCANT TO FILL IN . ewmiN� Cerlified copy is filed wi�h th county 6uilding inspeo- ADORE55 tion deparfinent. gUII�ING . ADDRE55 33 P �«A��TY Q � Dote �2? Applicont ' NEARESi n CER7IFICATE OF EXEMPTION PROM WORKERS' aTY /� Ziv 9 Cti055 ST.C', t�IZ r+ol�W O Qp 77!Z � COMPENSATION INSURANCE . SIZE OF ASSESSOR TRACT �/ LOT LOT NO. MAP BOOK PAGE iPRCFL (Thi�soc�lon n�d not 6o complNw!ii fh�permif is Mr ona �EL U5�ZPNE � MAP � bundrod dollan(SI00)or loss.) OWNER nip. �� � Np- � . I cenify rhat in the performance of the work for which ihis SpE�iq� i permit is issued,1 sholl no�employ any person in ony manner ADDRE55 2�/Q� �pNpITIONS so os ta 6erome subjecl ta the Workers'Compensation Lows. DISfRIQ STATISTICAL CLA55 TYPE PRO(fSSED BY CITY ZIP CANST. � . Dote Applimnt ARCHITECT OR TEL CIA55 NO. /] NOTICE TO APPLICANT: ff, after mok�ng�his Certificote of ENGiNEER Np. �O .Q(� Exemption, you should become subjecf to �he Warkers' VALUATION - Compensa�ion provis�ons of the Labor Code,you must forlh- A�RE55 wi�h compiy with such prov�sions o� rhis perm�� sholl be TEL s (� VALIDATfON deemed revoked. CONTRACTOR NO. ��f� UCENSED CONTRACFORS DECtARAT10N ���� 1 he+eby offbm thot I om licensed under provisions of Chap�er 9 A�DRESS w NO.3 = (commencing wifh Sedio�7000)of D�vision 3 of fhe Businesa ���� ond Pmteuions Code,and my{icense is rn fvH force and a8ett. C�iv Ctnss �^7� �? DESCRIPfION OF WORK � FINA1 � , � �1 D fl 9 A License Number_�.d�+�lic Class-�-� SWIMMING POOL � OAT6�� r #� � � �2� Confroctor - - �a�e ��' F�N�� ' a ❑ �-77�7 sc�.FT. sr � .. I ••4 9.p 9 c�.> I am exempt undee Sec. SIZE B.&P.C.for ihis�reason ELECTRICAL �� X�+- ' • `u y,Q�� � 03,27�-57 � oare � w $igrwture Steel 8 Conduil Bonding � 9 rC` N Conduifs,Conductors,Equipment ��� 0 d SINGIE FAMILY ' . Z ' HOME OWNER-BUItDER DECLARATION PLUMBING � � .N 1 here6y atfirm ihat 1 am ezempt from�he Conirador's License � ��(�)���(�fliil-��f/L L Law for the following reason(Seciion 7031.5, Business ond P-Trap � Professians Code): Gas System - �• I,as owner of the property,will do fhe plumbing and Anti-Syphon elecirical work.I,or my employees with woges os Iheir sole campensafion,or o licensed controCtor will do all MECHANICAL o�her work and the strocture is not iMended or oflered . � for sole($ection 7044 B8P Code). Swimming Pool Heoter �� � � � CONSTRUCTION LENDING AGENCV 1 hereby oNirm thai there is a construction lending ogency for APPI� T � � - the performonce of the work for which this permif is issued (pg�NT Np' !' /'iy � (Sec.3097,Gv.C.). J 7 Lender's Nome z 2 5 5,9 A � ADDRE55 // M��r• • �3 Lender's Address ,��� � • 1 7 5,5 Q . i P.G Fee S 7ermi�Fee - I tertify thal I have read Ihis opplimtion ond state�hat 1he � � ' • e � %,`,•,��� obove informotion is correU.I ogree ro comply wiih all Counfy `�. � � � ordinances and Stafe lows relaling to building, electricol, ies�o��e Fee - I �j�4—8•� mechoniml and plum6ing mnstruUion,and hereby outhorize ��•esrgoi�on Fee � �Q re tatives af Ihis County to enter upon ihe ❑6ove- Ta�al Fee � . enli ne propert s ectlon purposes. n b !�� � igrrot�re of Appliront or Agenr oaie SEE REVERSE POR E%PLANATORY LANGUAGE I ` , ` , ` ` ` \ ` � � \ � ' " � � � , _ `�; , o s , � ` +�► y C m 0 0� N D O � C L t �il O C O p ` U . 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