HomeMy WebLinkAbout1776A (19) WORKERS'COMPENSATION DECLARATION � �
I here6y affirm �hot I have a certificate of consent to self
insure,o�a certifitate of Workers'Compensation��s��a��e, APPLICATION.FQR COMBINATION SWIMMING POOL PERMIT
or a certified copy thereot(Sec.3800,Lab.C.) 76n408
-CE-875 01/81)
Vol' No. Company COUNTY OF LOS ANGELES BUILDING AND SAFE7Y "
Gertified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDINCa
�Ge��ified topy is filed wi�h rhe county building inspec- ADDRE55 Q
tion department. BUILDING r9
ADDRE55 +fTAL�-,yJ GO IOCAUFY W
Date� Applicant NEAREST�
CE IFICATE OF EXEMPTION FROM WORKERS' CITY �(/� ZW CRO55 57.
COMPENSATION INSURANCE ���'7 SIZE OF ASSESSOR
TRAC7 .,1) {� l0T LOT NO. M0.P BOOK PAGE PARCEL
(Thia s�cf{oe need irot ho complWod it tlw pormil is/or one - TEL. u5E ZcxdE. MAP
6undrod dollan(5100)or I�u.) Owr�e�/yl �/� �S / ��y�� � No. �Q � 3 -�+3
!certity that in the performance of the work far which�his � � ���qi
permi�is issued,I shall not employ an rson in ony manner E+DDRE55 / �� �' �� QD CON�ITIONS
5o as to beCo e subje[f to the W 5' )mpens ion Laws. DISTkICT STA715TICAL C1A55 TYPE OCE �8Y
CITV ZIP CONST. �
Oate � L APPlican ARCHITECT OR TEL. �5�.
NOTI T PPLICANT: If, ofl r oking Ihis Ceriificate of ENGWEER NO. �� 3
Ea ption, you should become so6jec� �o the Workers' � vAWAl10N
Compensotion provisions of the Labor Code,you-must forth- /+DORE55
with comply with such provisions or this permit sholl 6e TEL. s � � YAIIDATION
deemed revoked. CON7RA ��U�Q .�Nq. L�Sy�� '--'��Q� � �
LICENSE�CONTRACTORS DECLARATION ,IJ ���� Q i
I hereby affirm Ihot I am licensed under provisions of Chapter 9 ADDREu O FF�� � NO,�7/� I
lIC s
(commencing with Sec�ion 7000)of Division 3 oi 1he Business ��T ��O��3 • y �
and Professions Code,and my license is in full force and e4fect. d
DESCRIPTlpN OF WORK F�kAI - ` ( f �,'�� O
License Numberc�2��tic.Clas i '� . SW ING POOL � DATi ► �e • • • e? V �
Conhacfor pote � SPA � HNAL � �
� 1 am exempt under Sec StZE Z �Y ' s'Y�r n-J T W �
a
` N
B.BP:C.for lhis reason ELECTR4CAL � y , �
afe: �.�'i`' 9.,�'S_�J U J.C C-�l� �
� Sreel d Conduit Bonding e �'`N K r
Signo�ure Condoits,Conductors,Equipmant ,�g'-g�i �
SINGIE FAMILY 'E� �� f��
HOME OWNER-BUILDER DECLARATION pLUMBING Y���,p sf 3J l_L.�Z/ �
I he�eby affirm�haf I am exempt from the Contractor's License � �-• �i I"' �� [C 7 f�T
Low for ihe fo4{owing reosvn{Section 703I.5, Business and P_T�oP � � _ ,���i�_ �� i
Professions Code): Gas System ���_� �
� I,os owner af the properry,will do the plumbing and AntiSyphon ;
electricol work.i,or my empioyees with wages as their ����fG� Q�
sole compenmlion,or o licensed mntroctor will do oll MECHANICAL -
orher work and the structure is not intanded or offared ��J
for:ale�Section 7044 88P Code). Swimming Pool Heater Q . 1�^/'-2—�p -�
CONSTRUCTION LENDING AGENCY
I hereby affirm thal there is a construdion lending ogenty for �/"
the performance of the work for which this permit is issued A��pR�IN7� ryp aY/-,�y� �
�Sec.3097,Civ.C.). , .
Lender's Name ADDRE55 �,7D/��' (�C+v�� �
�O c�/-lr '
Lender's Address
P.C.fee S Permit Fee � �D �j �
I certify that I hava read this applitation and stote Ihot the � !� -
above informalion is correct 1 agree to mmply with all Couniy Issuance Fee � S
ordinances and Stote laws relating to building, elecfricol,
mechaniml and plumbing consiruction,and hereby aulhorize ���esiigotion Fee Q� �
� represe s of ihis County fo enler upon Ihe above- ToMI Fee 6 / �
me ' ned aperly fo inspedion purposes. , -
.3 Gz �
6 � Signature of Applicn gem D SEE REYERSE FOR EXPLANATORY LANGUAGE � I
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