HomeMy WebLinkAbout1416A 1644A ` ��AJ���l - WORKFRS'COMPENSATION DECIARATION � ;���;e� <'f':errifhm'ie of Workersr'Com'pensar on Insurance{ APPLICATION FOR COMBINATION SWIMMiNG POOL PERMIT or a a•rii(ied mpy thsreof(Sec 9600,Lob.C.) � 76nxa � eeere t3re+� volicy �o. ' Compony COUNTY OF LOS ANGELES BUIIDING AND SAPETY � Gertitied copy is hereby furnished. ❑ ` FOR APPLICANT TO FILL IN BUILDING Id t� �erliiied copy is Filed with the tounty bui�ding inspec- ADORE55�- O � tion department, � BU�LDtNG �p�ALITV � ADDRESS Dole APPliconl NEARFST CERTIFICATE OF EXEMPTION FROM WORKERS' ��rv � ZIP CROSS ST. l COMPENSATION INSURANCE SIZE OF � ASSESSOR iRACT q� LOT lOT NO. MAV BOOK PAGE, PARCEL (This s�dion n«d not ba complN�d li 16�p�rmH Is for on� � C {/` TEi. U5E 2oue hta.v ,Q '3� ��ndr�d dollor�(SI00)or I�a�.) OWNER (. (�li NO. � ��� �� �. 1 cert�fy thot in the periormance of the work for which this Sv��iA� ' permif is issued,I shall nof employ ony erson in ony manner ADDRE55 H� �Q CONDITIONS so os�o become su6jett to the Work Co ensaf� ws. ��iRICT S�ATIS11Cp.1 CLA55 TYPE FGOCESSED BV CITY Z�P �O C(ASS NO.�` CONST._ � Date�APPIi[ont ARCHITECTOR /� TE �� is.t�� NOTICE TO APPLICANT: If, ofter making r ertificot oF FNG�MEER (`� ��''���r E�emp��on, you shoU�d become subleU �o Ihe Worker5' VAtWTION � , . ' � ,Compe�sotlon provisions of�he lobo�Code,yowmust Fo�th- ADORFSS VAUOATION wiih compiy w�ih surh provisions or this permit shall be �L ' O�S NO. Z J s `` � deemed reveked. CONTRA�TOR UCENSED CONTRACTORS DECIARATION z (�J,�. �a �NO. 3( � , AODRE55 = . I hereby aff��m�hat I am licensed under provitians af Chop�er 9 n ��� 2 (mmmenNng wl�h Sedion 7000)of Drv�s�on 3 of rhe Bosiness Ciiy (� N� Cj ttn55�1-CS�7 � , and Professions Code,a d y license rs in full Torce ond effecr. ocs �ORK � O �,�{ FINAL license Numb 3�3 y u�.oa:5�� WIMMING POOL l�J--�/ o�r/ ► :='1 4 1,6 A �' � � � �. SPA l�J FIN '� •Z� � Contracro �ale V a6Y � I cm e.empi nder Sec. SiZE I ° '3 2.�� O D.BP.C.ior ihis.eason EIECTRICAL S� p�C1.1�,� • a e j�,�� � U Do�e: � S�eel 8 Condoil Bondinq P - �� --�sgbq � o y,�9-�r] z Signal�re � Condvits.Co�duc�ors,E ui ment SINGIE FAMI(Y - — HOME OWNER-BUIIDER DECLARATION PIUMBiNG ' � I herehy of(irm�hot 1 am e.empt irom the CoMractor's ticense � / � , , law for the follnwing reason(Sec�ion 7031.5. Bv:iness ond P•Trop � . _ , .(� ✓ � � _ Professions Code): [`,J,�-��\� •�� Gos System � � I,as owner oi rhe property,will do fhe plunbing and Anti•Syphon ��'�� _ � electrical work.1,or my employees with woges os thei� , _ \� sole mmpensoGon,or o Gcr,nsed convacio�will do all MECHANICAL . o�her work and the strucWre is nat intended ar o((ered �/ . � �� �7�',Q Fi For sole(Secrion 704a 68P Code). Swimming Pool Heo�er LU ' ' � . CONSTRUCTION IFNDING AGENCY �j � �O��U I hereby offirm Ihat there is a mnshu[lion lending agency for qpp�ICANT TEL. � � � ��� the performance oi the wark For which this permi�is Issued �pRINT) A(/(.. �. '�'7jfQ .NO 'Z � (Sec.3 0 9 7.Civ.C.). / ,A L �. .._.. . ��7.1 il"�7 �ender'S NOme AD�RESS ��{,/� /�I N-✓0 Ll�� G•'`� � lender's Address P.C.Fee E 1 Pe�mil Fee �/ 'd� �� � � I ceriify rhat I have reod ihis opplimiion ond state thot the �'j) . 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