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 .
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