HomeMy WebLinkAbout1277A 1713A � WORKERS'COMPENSF.fION DECLARATION �f � . � .
, '��s�,'ebo,a`�e°�,f cote ot WorAersr�Compensationlnsurancef APPLICATION� FOR COMBINATION SWIMMING POOL PERMIT �
or d certified copy thereof(Se<.380Q Lab.G) it;q2uB ' ' � ' ' � �
GFBf6�3/OA)
Policy No. Compony COUNTY OF LOS ANGELES , . BUILDING AND SAFETY
� Certlfied copy is hereby fpmished.
fOR APPLICANT TO fILL IN BUILDING I �N_.���_d(
� Ce�tified copy is filed with ihe[aunty building�nspeo - ADDRESS '��r y �
tion deporrmenf. .-�, � qDDRE55 � 3 S �1/� "� �'��t'�"'�`"'�-� ��`�
� I LOCALIiY .
Date Applican� NEAREST
CITY ' /f ZIP CRO55 5T.
CERTIFICAiE OF EXEMPTION FROM WORKERS' P�t SIZE OF ASSESSOR �
COMPENSATION INSURANCE 7eaC7 `T/��S .I. 40i LOT NO. MAP BOOK PAGE PARCEL
(This secfion need naf be complefad if}he permit is For one TEL IISE ZO MnP � e�,
hundred dollars(f100)or lass.) OWNER ' 1 /`� / NO. �^ �,-�i� NO. l ��� `E'
I certify ihat in the performan<e of ihe work for which this l,..� P CIAL
permit is issued,I shnll not employ any person in any manner ADDRE55 � 0 vy� NDITIONS
so as to become sublect to the Workers' mpens�tion Laws. DI 7RIQ STATISTICAL CLA55 7YPE PROCESSED BV
OtY 21F CCNST. _
CLASS NO. n
pa�p�qPp���o��i ARCHITECT OR TE�� oa•�L.
NOTICE TO APPLICANT: If, al r �akin this Cenificate of ENGINEER � � .
Exemplion, you should�beco subje 1 to ihe Workers" �n ` �y' VAWATION .
Compensation provisions of.the Lo or C e.you�musi forth- AO�RE55 ,_. __�� 1.}� G�?t" [�L�� �rry1 VqLIDATION �
� wilh comply with ;och provisions r t is perm.i� sholl be �EL,... _ s a� K-T/
deamed revoked. - CON7RACTOR � NO/ � /
IICENSED CONTRACTORS DECtARATION I,��r�- �� '�
ADDRF.5�,3,� qtSC.. �� D S
I hereby offirm thal I am licensecl under provis�a�s of Chapter 9 IIC. ,
(cornmencinc7 with Section 7000)of Divisinn 3 of the Bosiness ��TY �h/ � CLASS C.�j� � i L /:7�
and Professions Code,and my license is in full force and effect pESCRIPiiON pF WORK ' ��" a ' �'<� : �
c � FINAL
'LiCenSe Numbe.r ���(�� Li[.Class�'S3 � SWIMMING POOL �� LJ DATE� � -^�� , ' � ���r� a
u I G..,L.
�(,� �•�I SPA v FiNAI ;' �' / �� :� Y c:���:� O
Contracror��'��•�+ K'� Da�e_�� SQ.fT. BY � ' � .
�a� I am exempt under Sec SIZE '�°� �;1,�� ,_� ,� 0 .
8.8P.C.for ihis reason ELECiRICAL �'°"`�� ��(.a^- U
Date: {—�/ � � 0..
Steel 8 Conduft Bonding {--.-�_ � � � (A
Signature Co�duits,Conductors,EqoipmeN I T a�rf 6 � Z .
� SINGLE FAMILY ' � �/ � �
HOME OWNER-BUILDER DECLARATION pLUMBING f G �. ��y,�,��-•„(�j�;
'1 hereh afflrm ihai l am exem �from ihe Contrattoi s Llcense �t� - '���-'� ��' -
law foi the following reason(Sec�ion 703L5, Business and p_T�aP_ � �z.{,�,���1�� �, ,�� "l �,v A
- ProfessicnsCodel� �- � - �l�v � . ,
Gas Sysfem . 75� _
uI,:is owner oi ine properiy,wiii da rne pi�mbing and i�ntr$yphon L.� ' ��� /✓"'t:+� �_ f1-� '! ° �" °i.1
electricol work.I,or my empioyees with wages ns iheir . ` 1�^'��f
sole compensation,or a licensed mntrador will do all MECHANICAL 7�� � �iO��..�,Q
oth9r wark and tha str�c�ure is not intended or offered _
� foi sale(Section 7D44 B&P CodeJ. Swimming Pool Heater � '' "'J�i�),J il�
CONSTRULTION LEN�ING AGENCY ��� �.�(�...�'�
I hereby p4firm fh�t�here is o consiruciion lending agency for, APPUCANT 7/�.
the perfermc�ce of the work for which ihis permi�is issued (pR�NT}. �� NO�p 7�. �
(Sec.309I,Civ.G). .
le�der's�varoe �*-�NG ADDRF.SS � � � T� .
lender's A�dmss p.C.Fee E L a �z � Permit Pee �-�b'��� .
I cenify ihoi I hove reod this applica!ion and state that the p 7 ��
above Iniormohon Is correct.i ayree to compfy wlth a0 Couniy Issu ce Fee !O`�� ' �
ordinan�ns and State lows relating to building, elecirical, on
�B, mechanicnl ond plumbing cons�rurnon,�nd hereby authorize Invns�igniion Fee �� ,'�� � �
r� represeNativ s of ihis Counry to enter upon rhe above- Taiol fee , '�
mentioned pr per�y For insnec�ion purposes. - ,- ���� �
� ��r � .
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