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
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