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 . 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