HomeMy WebLinkAbout1402A 1636A WORKERS'COMPENSATION DECIARATION " • ���ryy��: ••, � � - .
I hereby oifirm thot I hove a cerlifica�e of consenl 10 seH � � � � �
insure,or o cer�iLcate af Workers'Compensarion��,�,a��e, �APPLICATION FOR COMBINATION SWIMMiNG POOL P RMIT
or o ce�tiFed copy thereof(Sec.3800,lab.C.) 76n20� .
Poi�c No.7N. 6 f,.,,,�p CF.876131ea)
y ____i.�_Company 5�� COUNTY OF LOS ANGElES BUILDING AND SAFETY
� Certified capy is hereby(wnished.
� - fOR APPLICANT TO FILL IN BU4DiNG � �, � c
Certified copy is filed with the county building inspec- AD�RESS � L
fion deporfinenf. BUIIDING
q � ADDRES$ Z V SET G�� I1`r LOCALITY � �. �
Date /f�l+.� Applimn NEa.REST �
CERTIFICATE OF EXEMPTION FROM WORKERS' �iTY fll Fl�h�O fjA ZiP CROSS ST.. [J L � U L_ �
COMPENSAT�ON INSURANCE TRACT ^L N 3 lOT�F LOT NO. IZ MAP BSOOK ' _ PAGE� PARCEL
(This sscllon nesd not 6a compbNd if 1h�permlt Is for ona C ���¢ iE. � _ useJfJN nMp ���3
hundrod doltars(floo)or�ass.� OWNER �N N . � NO.
I certify�ha�in�he performonte o(the work for which Ihis SPECInL
permit i5 i55�ed,I sholl not employ any person in any manner ADDRESS 2 UN CQ�_,$„r� CONDITIONS
so os fo become subject lo the Workeri Compensation Laws. � DISTRICT STATISTICAI ClASS+. TYGE PRp�ESSFD BY
CITY b�qmo,.+�p (Z � � IIP /� CONST.
Dote Applimnl ARCHiTFCT OR 1EL.��b� Z QA55 NO. � �
NOTICE TO APPIICANT: If, oiter moking this Cerlifimte af
ENGINEER g.G. I�DfaM NO. � � �I�
Exemplion, you should become sobject to the Workers' � - VfLUATION
Compensalion provisions of�he Lobor Code,you�musllorlh- ADD2E55 �IOZ7 fj[.q(�p p��. �Qpp'/(yLf�ry� � ' �
wiih comply with such provisions or ihis permit sholl be ' � VALIDATION
deemed revoked. CONTRACfOR Y�'bNR4 t� �^ � � ��� �C s �� �� -
LICENSED CONTRACTORS DECLARATION � � " - .
I hereb aifirm ihat I om licensed under AoosE55� o Cw YStl; Rn�Z'pC � .�i54 v b �
y provisions o1 Chopter 9 `� s
(commencing with Seclion 700p)of Division 3 of Ihe Business CITY LA(>JwW ��«S �e�• QA55 �- S
and Professions Code,and my license is in full force ond eifect ^ 3 ..`-� �l�,2{� �
DESCRIPTION Of WOFK FIMAL
�1�14'I 16 �J
Litense Number lia Closs�_ Sw�MM�NG POOL DATE I/��� ► t e � � 'z 1 y;
Conlroclor/�1D��/�/Lr1-f �.Dale 9�� SVA FINAl���7�/ � ° °u�,0 9 a.
❑ so.Fr. er l ��� . . �
f am eMempt under Sec. SIZE ��(3 �-+�7 n%j y(�C��
�
�6.8P.C.for this reason ELECTRICAI � ' Q Q�l R—�'] �
Date: U
Signo�ure � Steel 8 Condui�Bonding � Q.A i /J)�� , a
Conduirs,Conducrors,Equ�pmem ���Y � �f �
SINGLE FAMILY , . Z
HOME OWNER�BUILDER DECLARATION PWMBING /7f 9�p`� - - �
I hereby oFFirm Ihol I om eRempl{rom the Controcfor's License °K"VU
Law icr Ihe fCllCwing reason(Seclion 7031.5, Business and P-Trop � � � �� 6 J�.6 A
Professions CodeJ: Gas Sys�em �!X Q, S'<<' . �
� I,as owner of Ihe property,will do the plumbing ond ANi-Syphon +� � � � � �J
elecrrical work.I,or my employees with wages os their '
sole compensotion,or o licensed mnlrocror will do all MECHANICAL � � � � �M Jr�
oiher work and the srruc��re is not intended or offered � �
fer sale(Section 7044 BSP CodeJ. $wimming Pool Neoler � ' � e � � ']a J U,�5�
CONSTRUCTION IENDING AGENCY O C � 1 4�7 ,
I hereby offirm Ihot there is a construdion lending agency for qpp��CANT 7EL.
the pe�formance oI�he work for which this permii is issued r- . "
(Sec.309�,C��.C.1. . (PRINT) f���CCNC No.7�.�Q�oa
Lender'sNome- V+v�(lv���,� AD�RESS Zr O/�N�f/P�D'� ,Q1" �
Lender's Address (�p '� � �
P.C.iee E `_/'0 Permil Fee �'� -
i I certify tha�I hove read�his applimtion and siate�ha�the �1 ,,,,..... �'.,..F,i
' abore inFormolion is mrrect.I agree fo mmply with all County lesu�ce Fee � • �V '
ordinonces and Srote laws relating �o building, elecrrical,
mechonical and plumbing cansiruction,ond hereby au�ho�ize �^�esrgmion Fee a /� ��
representotives oi Ihis Counly to enler upon Ihe above- Ta�ol Fee �� �{/
mentioned roperty for nspection pu oses. -
Signotore of A�plimn�o.nge�� ---� SEE REVERSE FOR EXPLANATORY LANGUAGE� � �
D O u .D,� � � � m � y -_Zi � y N Z 2 = r�n /�`� - o O
'O � � � = N m A N' T! � !� Q O �1 � y
m � � = n• � r Z C � n W
n, n, :� n O � O
7 m � � z viu n ` O m Z A v'
'! -�i D A = m m = 7o Z � 't7
� �-1 �l � T T "'� N L H � n
n' � D^ D "� d
� �O t O °
< =z m z _ �
y �n
�
\ �
' 1 T � Z
�
� ° o
��
_ � m n • -
A � •
" � �
C
n
� � � q �
O d
-�1
Z '
. N
. '{�
I m
A �
O
t
O
a
2
' N
, m
. ' �
O
• �
, N
, , ' _ • O
• m
� , . N
� O � �� � O v+ � 'b Q'`C S b 7 W j-F G.^ v�a tn rl �-`O O W� S
0 0 �. ,� o c c o 0 0 � 3 ° � � o `o o� o � o c a c n
� � O� C N-n = � 2� � < C� F 7 H � � � �. N � 7 N � �. � J f�
' O .. O C' ry p�� O� O '�i rj S� � N n O a N � Q.C p� � � O N N 4 �
' � o n a� a � ' O � �. � � c N O`C p 4 v0 0 �.(j_ �
� a « o ° � S� a3o� `" o; a�'. nao� � m'ao '^.�a° �� a� �0
N.� o � -° ��� tr.n o � o v'" � F `, _'� m '�`b�c � �
' 3 '. 3 2 � > j . �� �C. � > >v o 'o_ o � ..�v° a�'o,,^�� " "' 3 0 0 3 7
, Z 'o n Sro d `� o a� • ��m` . �p � ��o ° �N � � 'e ' N' T rn
�n c � Q � � � 2 O '7 , O � Q � �: � n � O n K S c �D�M � O O A
N O �O 3 � � n o O � W �: r c n � cp— �
. n O � r! O N ] a p S 7'=O j b 4 7 j a� �- � �� i' O � 2 N !] 7 7 O C
. � � � 7 O > n o q n O F Q � U p � � 7 ��,^ 'n N �3 r
� �, 0 3- � a � '� s n a" � o o x �-,c -c ' rl o
A � F � i U � n� O.� b a o � j � o = O 7 7 m fl M :r_, c o O o m
�C `'o' °v „ o�° > ; o ° N4,� �� oa o0 3 °,ncvo � �F � �
^j �� „m � � � a o , o v � v Dti v � � o ' 3 O
� o o' -_ o. ^� �� � °.�.n? � o �� �,a o 3 o D1° v �l
� c�3 0' 3 - m' �
�O N O'.. G � _ � r
m ^a� � o . c T p � c o �' Q, f ° o _ < � ��� o � l ,�c, o "" D
• N � � o o� 3' o m N � ° S? � o a< �'c ° " ,n o=N �,� 0 3 Y
� �-F a , m ' � r� a � N o o c-�o u ov n �o � -�
m n a � !� � x 3 F o aso,� a Q q � � 0 3 3 a N o 0 o T �
a n i -�^ � � F ^ S 3 ;N � o �" � < a c � N 1�
� � � °,m T'c^ � �f � � ?o�.in� o o` o �a'> >..=.� n �0 e° � a.Z
n N i� ru <' � s . 3 p-'" n o o a�' sa'_� � � d� • �,
r1 m m o c
o ,°, o o �,� < ?o n c r'^ ,�N c m �n� v � a°3 � �
p > N� ] O O O j �S ry i v . 7 O n �O f0 �y� 0 O F p O
i O �7 0 O ^a j �O F, aa - o � O w 7��
M 4 O n n 7 S S] �� O O A � o �O _ �J . ? n
o �� _ m m �i • � � � a r q,. � N '^. �-o o, .o �-�,in N