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HomeMy WebLinkAbout1434A 1726A (8) ' W"JRKERS'COMPENSA?ION DECLARATION � I heroby offirm ihat I have a���,�F,�o��of�o�=����o S��f APPUCATION FOR COMBINATION SWIMMING POOL PERMIT � i�sure,or n reni(icnle ol Wc�kers"Compensation Insuron[e, � e.a ceriif�ed ce� ih reof(Sec.3 Lo 7gA,�g � � C=fi75�3/.'.<1 Poucy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY �Cr.riified ccpy is here6y furnished. FOR APPLICANT TO FILL IN BU�LD'vG terl�(ied copy is Filed wilh Ih ouniy b�ildinq inspec- AD�ESS ron d, gPn�rme��- eu�io�Nc�I :• ni�irae nooaess "I� SI '�► iocauTr �i Da�e.J6.�.!-y�.l—APPIi n NEAREST 1 1 - urv ziP ceoss sr. CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF A55[SSOR ' COMPENSATION INSURANCE TRAC7 S l07 LOT NO. S MP.P BOOK PAGE PARCEL �Thl���Nto�n�ed nel b�eemplN�d il lh�p�rmif It fer en� IEI. U5F Z04E nuP hundr�d dellan(5700)or I��s.) OwNER nro. rro. � �� I cer6fy!hot in:he pr.rformancr,o(�he work for which�his SPeCint pe�mit is issued,I sholl not employ ony pe�son in any monner aDDRF55 CONDiTIONS So as�o hecomr,subjrc7 to Ihe Worke�i Compensa�io�laws. DiSfRiC1 SfAiI511CA1 C1A55 TYVE PROCESSED BY CITY LP CONST p�fp Applicanl ARCNIiECTOR TEL. /� ClA$$Np NOTICE TO APPLICANT: IF, of�er moking ihis Certifico�e ai EyGiNEER NO. l.�Q ' '��� CS] � Exemplion, you shoulA become s�bjecl fo rhe Workr.ri � YAlUA710N . , Componsoi�on p.ov�sions ol Ihe Lo6cr Code,you musllcrth- ADDRF55 T�� YAIIOATIOH wi�h comply wiih s�ch provis�ons o� �his permit sholl be roNTRACTOR NO s deemed revoked. LICENSED CCNTRACTORS DECLARATION uC. I hereby oHirm�hnt I om licensed under provis�ons of Chap�e�9 ADDRE55 � NO. S IIC. . . (commenting wilh Setticn 700p)of Division 3 of Ihe Busines� �iTY C1A55 � � �--��-�-' � and Proless�ens Code,ond my licnnse is in full force and effect. , ;'� L:J.il�"i C� OEXR��TIpN pF WORK FINAI�I�/ M�,�/ l�ce�se Number�Lic.Class�—�•._ SwiMM��:G POOI �1� OATE�� (��(''" � , �; . . . •�� Con�r�c� Dale1ld_i�d y� SVA � u FINAL / � • ��C.r� } j � so.rT. ev ,. t o � I om exe.mpl vnder$ec. SIZE • s a j� ; I i, V B.BP.C.icr this rcason EfECTRICAL " ���C�_y(\�_ O Y.O 7—��� O Do�e: � �` � h $igno�urc S�eel 8 Conduit Bonding � ' `U Conduils,Canduttors,Fquipmen� ���� SINGIE FAMIIY � n' N HOME OWNER�BU�LDER DECIARATION FLUMBING . � Z I h�rnby nlff.m thm I om e.empt from!he Con'rncror's License � T(,� � Law for the following reoson�Secrion 7031.5,B�siness and P-Trop • �JSL� ��,,,1, � ProFessions Code.): Gns System � , C.)"' `a.+ � I,as owner of ihe pronerry,will do the plumbing and Anti•Syphon ele.clrical werk.I,or my employees wilh wagr.s as their C � eole compensa�ion,or a I�censed controctor will do all MECHANICAL ��+i Y oihe�wo�k a�d�he s�ruciure�s noi imended or of(ered � � � for sale(Seciion 70aa B8P Code). Swimm�ng Paol Hearer CONSTRUCfION lEN�IfvG AGENCY =�i !Z,i.� r�; I hrreby o((irm�tin�ihe�e is a consrruc�ion lend�ng ogency for qpp�ICANT� tFl. �� � ;; e e ihe perfc�mnnrr.of ihs work fo�which�ti�s pe�mir is issued �vaivT) hp � " °°;� �Sec.3097,Civ.C.). Lond�r'S Name nDDRF55. I � 1 ��� .,�•1 lender's Add�ess v.e.v�e s �l�mit Fpp �Q . ... � � � ��;;� „.:_ I cer�ify tha�I hnve read�his opplica+�on and s�a1r.rho�Ihe [��,�f•—„;� r.bovc iniormniion is corrrtrt.I agrec�o tomply wiih oll Coumy Issoa�ce F.e 6 e ordinnnces ond Stoie laws relo�ing io builAinq, rlethicol, mechonicol ond plumbing cons�ruction.and hernby a��horize ��ves�ipo�ion Fee . r� QO represen� �ives cf ihis Cauniy to ente� opon rhr, above- To�al Frte � o ed p�o rly for inspr.�linn�urpasr.s. s����w��or nnri�co�i o.n�r�i oa,e SEE REVERSE FOR ElI►LANATORY LANGUAGE Z o o • r .. r � 0' � � � � � � ` � O � �y p O '� , � 2 N � Q. O Z b � d .S, � � . 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