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HomeMy WebLinkAbout1416A 1644A (219) ` ��AJ���l - WORKFRS'COMPENSATION DECIARATION � ;���;e� <'f':errifhm'ie of Workersr'Com'pensar on Insurance{ APPLICATION FOR COMBINAT10N SWIMMING POOL PERMIT or a a•rii(ied mPY thereof(Sec 9600.Lob.C.) ' 76a2e0 eeere t3re+� Policy �o. ' Compony COUNTY OF LOS ANGELES BUIIDING AND SAPETY � Certitied copy is hereby furnished. ❑ " FOR APPLICANT TO FILL IN BUILDING Id t� Cerliiied copy is Filed with the tounty bui�ding inspec- ADORE55�- O � tion department, � BU�LDtNG �p�A�ITV � ADDRESS Do�e APpliconl NEARFST CERTIFICATE OF EXEMPTION FROM WORKERS' ��rv � ZIP CROSS ST. l COMPENSATION INSURANCE SIZE Oi I ASSESSOR , iRACT q� LOT lOT NO. MAV BOOK PAGE, PARCEL (This s�cllon n«d no}ba compld�d II 16�p�rmH Is for on� C {/' TEI. USE 20NE hta.v ,Q '3� ��ndrod dollar�(SI00)or I�a�.) OWNER G (�li NO. � �d� �� �. 1 cert�fy that in the periormance of the work for which this Sv��iA� ' perm�t is issued,I shall not employ ony erson in ony manner �DDeE55 H� �(� CONDITIONS so os�o become su6jett to the Work Co ensaf� ws. ��iRICT S�ATIS11Cp.1 CLA55 TYPE FGOCESSED BV y�Q/.y�'�, ❑TY Z�F �O C(ASS NO.�` �5_ T.(l � pate�-L�1l�Appli[ont .4RCHITECTOR /� TE �� I1�.V NOTICE TO APPLICANT: If, ofter mok�ng r ertificm oF ENG�taEER (J �v._r� E�emp��on, you shoU�d become subleU �o Ihe Worker5' VAtWTION � , . ' � ,Compensotion provisions oF Ihe lobor Code,yowmust Forth- ADDRESS VAUOATION wiih mmpiy w�ih such provisions or this permit shall be �L ' OLS NO. Z J s `` � deemed reveked. CON7RA�TOR UCENSED CONTRACTORS DECIARATION z (�J,�. �a �NO. 3( � , AODRE55 = . I hereby aff��m�hat I am licensed under provieions of Chop�er 9 n y� ��� 2 (mmmenNng wl�h Sedion 7000)of Drv�s�on 3 of rhe Bosiness Ciiy (� Nv Cj ttn55�1—CS�7 � , and Professions Code,a d y license rs in full Torce and effecr. ocs �ORK � O �,�{ FINAL License Numb 3�3 y u�.oa:5�� WIMMING POOL lJ o�r/ ► :='1 4 1,6 A �' � � � �. SPA � FIN '� •Z� � Contracro �ale V a6Y � I cm e.empl nder Sec. SiZE I ° •�2.�� O D.BP.C.ior Ihis.eason EIECTRICAL S� p�Cf.1�,� � a e j�,P� � U Dote: W S�eel 8 Condoil Bondinq P - �� --�sgbq � o y,�9—�r] z Signalore � Condvits,Co�duc�ors,E ui ment SINGIE FAMRY - — HOME OWNER-BUIIDER DECLARATION PIUMBiNG ' � 1 herehy af(irm�hot 1 am e.empl irom the CoMractor's ticense � / � , , law for the followin9 reason(Sec�ion 7031.5. Bv:iness ond P•Trop � . _ , .(� ✓ � � _ Prefessions Code): Gos System ���� •�� � � I,as owner oi rhe property,will do fhe plunbing and Anti•Syphon _ � elec+rical work.I,or my employees with wages os fhei� , _ sole mmpensoGon,or o Gcr,nsed convacio�will do all MECHANICAL . o�her work and the etrucWre is nat intended ar o((ered .—/ � � �� �7�',11 Fi For sole(Secrion 704a 68P Code). Swimming Pool Heo�er LU ' ' � ! . CONSTRUCTION[FNDING AGENCY `I � ?°^ I hereby offirm�hat there is a mnshuUion lending agency for qpp�ICANT TEL. � � u the erformance oi�he work For which this mit is issued n �O��` U p Pe� �PRINT) n.UL �. �/� .NO �� � (Sec.3097.Civ.C.). / L l n •� �. .._.. . ��7.1 il"�7 �ender'S Nome AD�RESS ��{,/� �v 0 vl�� v��~v � lender's AfJdress P.C.Fee E 1 Pe�mil Fee �/ 'd� �� � � I ceriify rhaf I have reod ihis opplimUon ond state thot the �'j) . ' � obave 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 mnslroU�on,ond herebyonfhorixe� �nvPS1igaeon Fee / Q.�,�O � representari� of ihis Cou ty to ente� upon the above- To�al Fee O _ � meniianP pr erry 1 i �ia purposes. �, � � ��a� =of �o� ge�� ote_�� SEE REVERSE FOR E%PLANATORY�LANG GE . � ' Z o ' o • - � ~ � � O � ^' .� P O o "' o' o Z '`�„ � 7" y zi O O x q. o . i � � G � O A n � .r � � � A 2 :a '.G � "� . C� 2 (�+ .. G "' -+ ' O �o ,� AO � y+ ,�o �. .'�[ M Z D , Z G � Y n = Z C� i� r n ` ��'- � '�'" �ft y �0 � � � � L ` N � N L , p � A Or � �, n 7� T!� i � 7 ?, o �, � � x � ��^. m o o r a� a p .n � �ap d yi � y a � �' �Z \'�... \ M a y C? 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