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
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