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) . ' �
obove information is mrreU.I agree b tomply with al�Counly - Issuance Fee �d"� � . �
o�dinances and 9a�e laws relating to bu�lding, etectricol, . 1
mech�nicol and plam6ing mnslroUion,ond hereby oufhorixe� �^v+�'gaaon Fee / Q.�,�O
� representoti� of ihis Cou fy to enfe� upon �he above- To�al Fee �
� meniiane pr erry 1 i �ia purposes. �, � �
��a� =of �o� ge�� ote_�� SEE REVERSE FOR E%PLANATORY�LANG GE .
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