HomeMy WebLinkAbout0948A 1093A WORKERS'COMPENSATION DECLARATION ' �� � ��- � ; �� � � �
I hereby affirm that I have a certiiimtPe a+consent�o self App���AT10N FOR COMSlNATION SW{MMiNG POOt PERMiT
insure,o�a cenificate of Workers'Com ensation Insurance,
or a certified copy thereof(Sec 3800,La6.C.) 7en2aB
PoTic�Yro'�om on LC1�7�1� iT�` cEs�sl3�ea)
p r COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is here6y furnished. `
� BUIIDING � V��.
� Certifiad copy is filed wi�h the county building inspec- FOR APPLICANT TO FILL IN ` qpppEgs ( '
lion epar ent. BUILDING /�� �`����
ADDRESS �� Sl��� �.AJ LOCALITY �!""—�]{�D
Oate �Applicant
CITY NEAREST /
CERiIfICA7E OF EXEMPTION FROM RS' � Z�P CROSS ST. !'�/7 � ���v
COMPENSA710N tNSUHANCE 512E OF ASSESSOR .
TRAQ t0T LOT NO.� MAP BOOK PAGE PARCEI
(This��cfion nNd nof be mmplWed if th�permlf 1�ior ono �� p� TE1���n USE ZOnIE MAP
bundrad dellan(;100)or Was.� OwNER - �/�a`,/�; Nd'..ao<7 � �`r Np.
1 cer�ify that in the performance oi rha werk for wh'rch this r'� � v� (`7� SaECiqi
permit is issued,I shall noi employ any person in any manner ADDRESS `^T ' 1�/�1� CONDiTiONS
so os to become subjecl to the Workers"Compensation Lows. DISTRICi STATISiICqL CLA55 TYPE pROCESSE�BY
ar�i�°J'y ziv q� 1�', coNST. ,
Date A liwnt ARCHITECr TEL C��^��.
NOTICE TO APPLICANT Pf. af�er making this Certificate of ENGiNEER NO. ) 7 �r� �
Exemption, you should become suhject to the Workers' VAtUAT10N
Compensation provisions of the labor Code,you must fo�th- A�ouE`'S
�`.� VALIDATION
with comply with s�ch provisions o� �his permi� shall 6e COn1TRaC� NO. nc� s �2 V 1
deemed revoked.
LICENSED CONTRACFORS DECIARATION uC. ;
ADDR
{hereby offirm that I am licensed under pravisions of Chapter 9 � V��� ` S �
(commencing with Sedion 7W0)of Dirision 3 of the Business ���' �
and Professions Code,and my license is in full force and effect OTY � CtA -.O Y A,4 N, �
DESCRIPTION OF WORK
��0� FiNAI � ;y'.• • o •2� . �
License Nvmber Lic ClosseS� SwV.vnING POOL CATE � ��
e-77� srn • �^ a
Confra����� Date `� '� FINAI �� J � �.�I O
� SO.Ff. � BY � a o .�.�? � � �
I am exempr under Sec. SiZE =�
B.$P.C.for tbis reason ELECTRICAI � ��� ��� ''� � � ��"7 V
Dote: � W
Steel&Conduit Bonding n- �
Signoture Conduits,Conductors,Equipmenl �S6� �
SINGIE FAMILV � z 1 0�3 A Z �
HOME OWNER-BUILDER DECLARATION PLUMBING � �� � � � �v �
I here6y affirm rhot�am exemp�from tha Contracfor's License
law for 1he foilowing reason �Section 7031.5, Business and P_T�aP f o .� �Q G�
Professions Code): Gas Sysfem
� I,as owner of�he praperty,will do the plumbing and An�i-Syphon • ° I :�G U�
electriwl work.I,or my employees with wages as their
sole compensotion,or a licensed con�ractor will do all MECHANICAL 0 8.C'��8 7
other work and the structure is not intended or affered
for sale(Secrion 7044 88P Code). Swimming Pool Heater I
CONSTRUCTION LENDING AGENCY �
!hereby pffirm thot�here is o conslruttion lending agency for �
APPIICANT TEL.
1he performonce of the work for which this permit is issued (pg�NT) P r � � ��
(Sec.3097,Civ.C.)
Lender's Nome�'� ADDRESS—b�Cl }�a �U L '
Lender's Address p.C.Fee f �Z e Pe.m�i Fee ��7���
I ceriify thoi I hove reod th�s application and srdte that the '.
above information is carecL I agree to comply with all Counry !�, S"�
ordinonces ond State laws relating to building, eleclrical, Is:uance Fee
mechanical and pl�m6ing construction,and heieby authorize ��+es�iganon Fee p !
representatives ot fhis Couniy to enter upon �he obove- Total Fee �p i � � � �
me rone ty for inspedlon purposes- . �
r . �•��� I
Sign ture of Applimnl ge�i Daie SEE REVERSE FOR EXPLANATORY LANGUAGE ;
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