HomeMy WebLinkAbout1836A 2516A (11) ( `
WORKER$'COMPENSATION DECLARATION
I here6y affirm ihb�I hove a certifkate of consen�b sel( qpp�fCATI�N FOR C�MBINATION SWIMMING POOL PERMIT �
insure,or o ceriificme of Workers'Compensation Insorance.
o�a certif d copy fhereoi(Sec.78 tob.C.) 7fia2C8 '
CEe1s 19�eq
Pol�cy N �Compan COUNTY OF LOS ANGELES BUILDING AND SAPETY
� Cerhfied copy is hereby fumishe .
BUtI�ING ij�
Ce�tified copy�s filed wirh rhe counry buil ' Inspec• FOR APPLICANT TO FILL IN AODGE55 L
tio�deportment. Bl11LDING �
ADDQE55 LOCALITV
Doie.��iAppiitant NEAREST � � �
CITV ZIP fQOSS 5T,
CERTIF�CATE OF EXEMPTIO f M WORKERS' S�ZF Qp p5SE5SOR
COMPENSATION I U ANCE TRACT LOT LOT NO. I 1AP.P 800K CAGE PARCEL �
(Thh��Nion nNd nof 6�cempl�fe th�p�rmi}b lor oa� 1FL USE ZCNe MAP F' C�
hundrsd dollen(SIDO)or I�u.) OWNER NO. — r�0. 1 � `"l 3 1 �
I terlify thaf in�he performance of Ihe work for which Ihis ���A��
permft is issued,I sholl nat employ any person in any manner A�DRE55 CONDITIONS
so os�o be[ome subjecl lo Ihe Workeri Compensolion lawe. � DiSTRIQ STATISIICAL C1A55 TYPE VNO�SSED BY
CITY ZIP CONST, �
Oale Applimnt ARCHiTFCTOR TE� ,� GLASSNO. � � Z'�
NOTICE TO APPtICANT: If, o{1er moking Ihis Certificote oI ENGMEfR NO.
E.emprion, you shou�d become subject to the Workers' - I VALWTION .
Compenw�ion provisions of�he lobor Code,yoa musl fortfi- ADORE55
with comply with such pro�is�o�s or this permit shall be TEI. n = VALICATION
deemed revoked. CONTRACTOR r NO. � 'i
IICEN5E0 CONTRACTORS DECLARATION � � ���'
ADDRE55 �
1 hereby aHirm that I om licenSed under proviiions of Chapter 9 � LIC. s :1 �J.iJ i�
(commencing with Sedion 7000)of Oivision 3 of�he Businass ��T� CUtSS - �
ond Profess7ons Code,and my license is in loll fo/rtle an�d effecl. pESCR:pTiON OF WORK FINAI ► 't� � � °r'�
license Num lic Clas{1��-.,2_ SW�MMiNG POOL � DA7F � I �• �7 U.I ., �
Controh 1 O�t'Cn �e G-1 -�1 SPA � FINAL e � e�j fl 1 '��, a
SQ.FT. !Y . �
� I om exempt onder$et. S�ZE � �0'�j o� U
—u�.:
B.BP.C.foi�his reasan ELECTR�CAI � �
Date: �
Si noture Steel 8 Conduit Bonding 'B � � . W
9 Canduils,Conducfors,EquipmeM 0.
SINGLE FAMIIY � fq
HOME OWNER-BUILDER DEGLARATION PLUMBING - ' ,.. Z
I hereby aifirm thot I om ezempt from the Conlroctor's License � . �� � �=�G�I,.�'�!�I
law for the follawinq reasen(Secticn 7031.5,Businest and p.Lop � . .
Proteseions Code): Gao Syslem . �� �. � � ��
� I,os owner of�he prope�ty,will do�he plumbinp and Anti-Syphon � • 1 �II`l�
electricol work.1,or my employees with woges os their
sole compensmion,or a licensed conlrouoi will do oll MECHANICAL � p .;,-,
afher work and the seructvre is nof iMended or offered � � " 1 �`��'�'
for sole�Se<tion 7044 88P Code). Swimming Pool Hea�er � � O.� �—v&
CONSTRUCTtON LEN6ING AGFNCY . - � '
i�, .
I hereby ofhrm ihat there is a construUion lending agenry(or APftICAN� 'E`. 9R
tfie performance of the wo�k for which th�s permit is Sssoed pRiM p�p. "
(Set.3097,Civ.C.�. ,. .._..._ .
tender's Nome ADDRESS� � � - �
lend^r's Address v.0 Fee S l O.,� Pe�mn fee S�J
I ceriify tho�I have read�his applica�ion and state that�he
obave informarion is correU.I ogree�o comply wiih all County /V��j .
ordinonces ond State laws relo�ing to bu�lding, electritol, IssuoncaFee
mechaniml ond ptumbing consiruUion,ond he�eby vulhorize �^�es++go��on Fee / Q G a �
represema�iv of this C �o eNer upon the above- Torolfee O 0
men�io d pr er� {or i peclio purpotes.
Sq�a . of qp �com o�Ageoi Daie SEE REVERSE FOR EXPLANATORY UNGUAGE
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