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HomeMy WebLinkAbout1262A 1414A (6) IWORKERS'COMPENSATION DECLARATION 1 hereby afiirm Ihof! hove a�e,��f,�afP of conseni ro,e�t ppp��CATIQN FOR COMBINATlON SWIMMING POOL PERMIT � I insure,or a certificote of Workers'Compensation Insurance, � or o certified copy�hereof{Sec 380Q Lob.C.) 7snzo6 I7olicyNo. ���Companv�a`Z-�t)^�'k � �;eU�sf�rA4� � Certified co y COUNTY OP LOS ANGELE$ BUILDING AND SAFETY iV py is hereb furnished. �! FOR APPLICANT TO FILL IN BUILDINC� g� s er�i£ied copy is filed wilh tbe counfy building inspec- ADDRE55 ���� ��U 1"�f�'��� Y�((;J' tion deporfinent. BUILDING e p � Dafe�'����� APPlicant ��� � ADDRESS ���� �]���\� 4 L• LOCALITY �N�bN� CITY�j3a-�yr+ NEAREST ��AQ,� ZIP �l � CROSS 5T. ��✓��.N CERiifICA7E OF EXEMPiION FRO WORKERS' S�ZE pF q55E550R i COMPENSATION INSURANCE TRACT ��Z S� LO7 LOT NO. ��'J MAP BOOK PAGE PARCEL � 1 (ihis secfion need nof 6e compfeied N 1he parmlt Is for one yZ N J � hundred dollaro(SI00)or less.) � OwNEt1 A1�p�.��„j �� Np�.yy�}—'�� �S�+�j�E� NO� ,/f—e.� i certify that in Ihe pertormance of Ihe work for which ihis ��� i (� (� �1 SPEC!AL permit is issued,I sholl not employ any person in any manner �. ADDRE55`��S �J%�tl'\,a����..(y �' � :s�{1(jG'd,� CONDITIONS � so os lo become sub jecl to ihe Workers'Com pensof i on L pws. '�, CITY �; �p}J �¢�.'r Z�p t�� DISTRICT STATIS71CAl CLASS CONST. PROCESSED BV Date Applimni • ARCHITECT OR TEL j CLASS NO. �+� �l� NOACE TO APPUCANT: If, after making this Certificate of '- ENGINEER No. 7� `"� �T��'' �€ fxe••,p•io.+, yo„ chould become subiecl to ihe Workers' VALUATION Compensation provisions of 1he labor Code,you mu:t for�h- HDt�"�'� i with mmpiy with such provisions or this permit shall be (�y � � TEL. rt s� ' �A��DA��ury -deemed revoked. ��'CON7RAC70R(°\� +ii�j 9p � NO. � �'�/ � LICENSED CONTRACTOR$DECLARATION r °� i c, LIC. , 9 1 hereb affi�m ihat I am licensed onder e ADDRE55`.�,�y ih�` .d 0..l Q � NO.� � � y provisions of Ch+apfer 9 ¢+ s I b,z, '"� , �(commencing wi�h Section 7000)of Divislon 3 of the Business u CiTV C�!/�� C ASS�' .]� � ""'"�� . and Professions Code,and my license is in Fuli Sorce arttl effecL '� � o��l % S % DESCRIPTION OF WORK � � License Number��'�`a�� Li[.Class`�-' � �� SWIMMING VOOL DA EL Q•'�:� ► �p �q � �.{�.--{-,7�� � :Caniratlor' T'����S Date �T�`^� > SPA ' �J FINAI : . � s�.F� �/�` } I am exemp�unde.r Sec__ � SIZE 7(7� �Y � LL 9 � B.BP.C.for this reason �� ��.:r_t� O � � ELECTRICAI .. „ Date: �c c n c�- �.^ Sieel 8 Condurf Bonding �/�' o Signature � F'7t U ` '" r ) fJ r✓i.� u ~ ,Sr.t� l +3 J ( n7ti.Q4 Condvits,Conductors,Equipmeni 1 c� V � SINGLE FAMILY � �U !� HOME OWNER-BUILDER DECLARATION � pLUMBiNG �ti�� ��� �L`'S " �0 " r'`���? ffa ! I hereby offirm thol I am exempt from ihe Confracfor's licanse � ► � Z � �Law for Ihe following reason(Sec�ion 7031.5, Bosiness ond §? � �i�e?�1"�i 75 '— Profo<s;n�.r'pae)� i�. P-Lop . � �o,Sys!am . � �❑ I,os owner of fhe properfy,wili do fhe plumbing and � AMi-Syphon �� electriml work.I,or my employees with wages as their �. sole compensation,o�o licensed mntractor will do all �'e� MECHANICAL other work oad the structure is not intended or offered .� � � for sale(Section 7044 B8P Code). � Swimming Pool Heater �� ���- , , . . i � CONSTRUCTION LENDING AGENCY � ' � I hereby affirm that there is a construction lending ogenry for I � A7PLICANT '��� TEt � �'.�5 t[. � 1_'.Y� the performance of the work for whi<h Ihis permit is issued t�; (pp�NT)� � �,�� ��;��g��� N�/_`�j�,,'�� � , '�(Sec.3D97,Civ.C.). �; e-.C-�;Rdw� I Lender's Nome ',���,' ��cT(/i� ' �' � �T"'� �j.a 3 r r '::J ', ADDRE55 � � . � �$�������z Lender'S Address � +^ ,J'I �y �!i c � ��' P.C.Fee S ��S`1"`�" Permi�Fee ��� +�R � 7 ce�r�fy th�l 1 have read this applicafion ond stote thof fhe '�" � � �+/ � above Information is correcL I ogree to mmply with oll County � + �•�.�3 �.�la,�'� �'�(� ordinances ond Stote lows relating to building, electrical, Issuanca Fee methoniml and plumbing conslruciion,ond here6y authorize � �^�esegormn Pae [ -} repres nto�ves of this County to enter upon the above- � TotalPee ,"'�' °-`�� � men� n pr ly fo�inspettion purposes. � � °�__ � �'--�_ -y'�- � Sig� `e oF Applic t or Aqe�� oote ,i SEE REVERSE FOR EXPLANATORY IANGUAGE � � � Q � � v: t '' t. `�-t� n °. 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