HomeMy WebLinkAbout1402A 1636A (7) WORKERS'COMPENSATION DECIARATION , \��/f./�� , . � ' I I
insure6or o{ce��hcate af Wo kers',Com'pensar on��s��a��e`, �APPLICATION FOR COMgINATION SWIMMING POOL P RMIT ��
or o ce�tiF�ed copy thereof(Sec,9800,lab.C.) 76n209 �
CF.8761378a)
Policy No.7x 6 Company�• f•""� . COUNTY OF LOS ANGElES BUILDING AND SAFETY
� Certiiied mpy is hereby iurnished. BunDtNG O
� Certified copy is filed�.+ith the cou�ty 6uilding inspeo- - fOR APPLICANT TO FILL IN nDDRE55 ��n � �-` C
fion deportmenf. BWIDING
' ADDRES$ 2 V SET G�� I1`� LOCALITV � -
NEARE51
Date��Applimn CITY flIL��'sih�O �A ZIP CROSSST.. C:. L � UL. .
CERTIFICATE OF EXEM.PTION FROM WaRKERS' +�^�� SrzE OF �7 aSs�S50a � �
COMPENSAT�ON INSURANCE TRACT ^L N 3 lOT LOT NO. /K. MAP BOOK � _ PAGE� PARCEL
(TMi seellon ne�d not 6a eompl�bd if tb�p�rmlt Is for ono ie. � ' usEJ{�tiF MAv ���3
hundr4d doliors(f100)or lass.) OWNER L �E'I�LQ�N N . _ K J NO.
I certi(y thar in ihe performance o(the wo�k for which�his $�-..:� SPECiAI
permit i5 iss�ed,I sholl no�e,mploy any perso�i�ony manner ADDRESS 2 UN CQCfiS Hv� CONDITIONS
so os ta became subjecl�o the Workers'Compe�salion Laws. � DISTRICT STATISTICAI C1A55-�. 1YGE PROCESSFD BY
CITY�O\'AVY10+�+1D FZ C . ZIP /�` CIASSNO. . CONST. �
Dote Applicanl ARCHiTFCT OR 1�6'�b—o.2q � ���
NOTICE TO APPIICANT: If, aiter moking this Cer1i(imte of ENGMEER $.G• A�AM "�
Exemplion, you shou�d become s�blect lo rhe Warkers' qpDRE55 11022 F�[.Nti A P1L�- �Qt7P�✓6�-ntS1l ���UATION � • �
Campensalion provisions oi Ihe Lobor Code,you mus�for�h- �„ � s ;D �, � � � VALIDATION
with mmply with such provisio�s or ihis permit sholl be �NTRACf04'(�'�oNR4 �u- �^ L � . . .
deemed revoked. . � r^ �
IICENSED CONTRACTORS DECLARATION qpDRE55ZS O C11�r: RD k Z'�' � �y54 2�b =
I hereby oifirm tha�i om ficensed under provisions oi Chop�er 9 i��.
(commencing with Sedion 7000)of Division 3 of Ihe Bosiness UTY 4A(>JwW ��«S �e.• tta55 G'�s3 <<�i 4 0,2 n �
and Prafessians Code,and my license is in full forcE and eifecl. DESCR�PTION Of WCRK �) �
FIMAI / � �`( / t e �z�
licen5e Number��?1h li[.Glass �—S� SWIMMING POOL � DATE //��� / ► • n 1"
���,,)JJ � ° �49,09 a
CoNrOt�Or/�1D��/}�+'W ��.Dale� /�7 57A FINAI�_,r,/7[J • i �
so.rT. �i t3 eY `��'/�7��� ,�%1 9 0 9:i �
� 1�am eMempt under Sec. SIZE
.B.BP.C.for this reason ELECTRICAI a���R-�7 OU
� W
Do�e: � Sfeel 8 Condui�Bonding ���=�7{ � „/ . . � ff�
Signolure Condairs,Conducfors,Equ�pment �5J � � , Z
SINGLE FAMILY fq� �. . .
HOME OWNER�BUILDER DECLARATION PWMBING ► .c.�8(�9
I hereby oFFirm ihol I om ecemp�irom the Confrodor's Lkense � ..
law icr�he fcllcwing reasan(Sec�ion 7031.5, Business and P�Tro � `� 6 3'6 A
Professions CodeJ: Gas S stem C:X 1�• S �` -
Y
� I,as owncr of Ihe properfy,will do the plumbing ond ANi-Syphon � � � � � �`�
eletrrical work.I,o�my employees with wages os their � � � �M 5�
sole compensotion,oi a licensed mnrracror will do all MECHANICAL . �
oiher work and the sttutivre is no�intended ar ofiered � - .
fer sa�e(Section 7044 BSP CodeJ. $wimming Pool Heoler ' ° � � 7'�J U J
CONSTRUCTION IENDING AGENCY O�.� � "H 7
I hereby offirm�hot there is a construction lending agency for qpp�ICP.NT TEt. � . �
rhe performance oi�he work for which ih�s permi�is issued (pRINT) �,py�CCNC NO.J'�f�1bQ ► _ . _
(Sec.3097,C��.C.�. .
tender's Nome V��Hd��.� AD�RESS zr o/C�I�f/Pp'� � �� - � � �
lender's Address P.C.fee E �"/'0 Permil Fee �p
I certify tha�I hove read�his appliw�ion and s�ate 1ha1 the 'l . ""���� � -� �v������.` .
�� obove inFormolion is mrrect I agree ro mmply wlih all Counry lesu ce Fec � • �V
ordinances and Srote laws relo�ing lo building, elecrrical, °O ..
mechoniml ond plumbing consiruction,ond hereby au�ho�ize ���PS��gm�on Fee ,. /S
representaiives oi �his County to eNer upon �he obove- Ta�al Fee �� �V .
menflo�ed roperty fo� nspection pv oses.
Signatore of A�plimn�o.age�� ---� SEE REVERSE FOR EXPLANATORY LANGUAGE. � � ,
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