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
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