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HomeMy WebLinkAbout1836A 2516A ( ` WORKERS'COMPENSATION DECLARATION I hereby affcrm ih5�I hove a certificate of consenr�o sel( APPLICATI�N FOR C�MBINATION SWIMMING POOL PERMIT � insure,or o ceriificme of Workers'Compensation Insorance, ot a certif d copy fhereoi(Sec.38 tob.C.) 7fia2c8 ' CE87s 19/Bq Pol�cy N �Compan COUNTY OF LOS ANGELE$ BUILDING AND SAPETY � Cerhfied copy is hereby fumiihe . BUtI�ING �� Ce�tifed copy�s filed wirh rhe counry buil ' Inspec FOR APPLICANT TO FILL IN AODGE55 tio�deportment. Bl11LDING � 1�— ADDQE55 LOCALITV Dote.'��zApplimnl NEAREST � i � CITV ZIP fQOSS 57, CERTIF�CATE OF E%EMPTIO f M WORKFRS' S�ZE OF ASSESSO4 COMPENSATION I U ANCE TRACT LOT LOT NO. I 1AAP 800K CAGE PARCEL � (Thtf��Nion nNd nof 6�cempl�b th�p�rmi}b lor oa� lEt. USE ZONE MAP F' C� hundrsd dellen(SIDO)or I�u.) OwNER No. — r�0. 1 � `"l 3 1 � I cerGfy tho�in ihe performance of ihe work for which ihis SVECiAt � permft is issued,I sholl nat employ any person in any monner A�DRESS CONDITIONS zo os�o be[ome subjecl lo Ihe Workeri Compensolion lawf. � DiSTRiQ STATISIICAL CtA55 TYPE VNO�SSED BY CITY ZIP CONST, � �ale Applimnt ARCHiTFCTOR TE� 1b GLASSNO. � � Z'� NOTICE TO APPtICANT: If, o{br moking ihis Certificote o� EhGiNEEe NO. Eaemprion, you shou�d become subject to the Workeri - I VALWTION . Compenwtion provisions oi the lobor Cade,yoamust fortb- AOOaE55 with comply with such pro�is�o�s or this permit shall be TEI. n s VALICATION deemed revoked. CONTRACTOR r NO. � '1 LICENSED CONTRACTORS DECLARATION � � ���' ADD4E55 � 1 hereby oHirm thal I om litensgd under provisions of Chopter 0 � LIC. : :1 �J.i7 i� (commencing with Sedion 7000)of Oivision 3 of�he Businass ��T� CUiSS - � ond Professions Code,and my license is in ioll fo/rtle anCd effecl. pESCR:PT�DN OF WDRK FINAL ► 't� � � °r'� license Num Lic Clas{��-�.,2_ SW�MMiNG POOL � DA7F � � �• �'�G.I . , Controc4 1 U�'Cn �e G-1 -�1 SPA � FINAL e o e�](1 1 '��. a SQ.FT. !Y . � � I am exempt onder$et. S�ZE � �0'�j o� U —u., B.BP.C.foi�his reasan ELECTR�CAI � � pate: � Steel 8 Conduit Bonding 'B � � W SignoNre Canduils,Conducfors,EquipmeM -� " 0. SINGLE FAMIIY � fq HOME OWNER-BUILDER DECLARATION PLUMBING - ' ,.. Z I hereby aifirm thot I om ezempr from ihe Con�rocror's License � . �� � �=�G�I,�!�I law for ihe following reason(Secticn 7031.5,Businest and p.Trop � , . Proteseions Code): Goo Syslem � . �� �. � � �� � I,os owner of�he prope��y,will do�he plumbinp and Anti-Syphon � • 1 �II Ll� eleciricol work.1,or my rmployeas with woges os their sole com ensmion,or a licensed conlrauoi will do oll MECHANICAL o�her work and the structore is no1 intended or offered � � � " 1 ���`i�'`' for sole�Se<tion 7044 88P CodeJ. Swimming Pool Hea�er 0 � Q� �_�& CONSTRUC7fON LEN�ING AGFNCY . - � ' i�, . 1 hereby oN�rm ihat there is a construUion lending agenry(or APftICAN� TEL. �R the performance of�he wo�k for which th�s permi�is Sssuad pRiM p�p. " (Set.3097,Civ.C.�. ,. .._...- . tender's Nome ADDRESS� � - � lend^r's Address P.0 Fee S �O.,J Pe�m��fee S�J I ceriify thot I have read�his applicalion and state that�he obave informarion is correU.I ogree�o comply wiih all County /V��j . ordinonces ond State laws rela�ing to buildinq, electricol, Issuo�caFee mechaniml ond ptumbing construdion,ond he�eby ovthorize �^�es�+go��on Fee / Q G a � represemaiiv of this C �o enier upon the above- Torolfee O 0 meniio d pr er� tor i peclio purpotes. S�g�a r of Ap �con�o�ngeoi oaie SEE REVERSE FOR EXPLANATORY UNGUAGE � 2 � _o � _ Q - " . � ''' � ,• . m ,�- � � � . ' f� O `'^ � � N D � O Z .O O x b � y�' O m � :: � . � 9� ' � G� '.C �n O `-.'. '�' y A A T '� .y ' y T r � r � Y n � L t � • � � . .� � � i- [� S !"'�. p � O Z O �� 9 • �' _. N � M G t� • ' � m � . 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