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HomeMy WebLinkAbout1277A 1713A (6) � 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 � . �? r- - 1 .. ` "��,e o qP�l��o�i��nqd�,i o���e . 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