HomeMy WebLinkAbout1135A 1328A (5) � WORKERS'COMPENSATION DECLARATION � �
I hereby affirm�hot I have a certificate of consent to selF [�
insure,or a cerlificale of Workers'Compensation Insuronce, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT ��
or a certified topy thereof�Sec.3800,Lab.C.) 76azoo � ��
��g����^�f�(� r��. � �--. CE876(7/8a) LI
Po iCy o. Compony r�C�I.�BwJI , COUNTY OF LOS ANGELES BUILDING R�1D SAFETY
� Cerrified copy is hereby furnished.� �
FOR APPLICANT TO Flll IN BUiIDING � � O x ,f.
�ertiFied topy is filed wilh Ihe[ounly building inspe[- ADDRESS
tio d porlme��. BUILDING 2
ADORE55 Z jD TD GI lOG4lITY �/J
Dale Applicont � NEAREST
CERTIFICATE Of EXEMPTION FROM WORKERS' C�T Q Z�P rJlo S [RO55 5T.
COMPENSATION INSURANCE .�c� SiZE OF � ASSESSOR
TRACT +.V LOT LOT NO. 9 MP.7 BOOK PAGE PARCEI
(Tbis s�dfon nwd not b�complH�d if 1M p�rmlt it!or on� d TEL.��_ O U�E ZONE ; �P �O_
hundr�d dollan(;100)or las�.) owNEe /C,/[/[ No (7
' I certify that in ihe performance oi ihe work For which this / � �`�I SVECInI
permit is issued,I sholl no1 employ ony person in ony monner ADDRESS /t �� UiR7 �CONDITIONS
� so as lo become subje[t lo Ihe Workers'Compensafion Laws. 1� ! DISTRICT _ SiATISTICAI CtA55 TYPE PROCESSFD BY
; �iTY D./.�t,fL- Z�P g �b s ,�LAu NO. �ONST.
� Do�e Appliconl ARCHITEC�OR TEL. � � �
NO110E TO APPIICANT: If, ofier moking this Certifico�e of ENGINEER NO.
Exempnon, you sho�ld become subjeU lo the Workers' " VAtU�TwN �
Compensotion provisions of tho labor Code,you must forlh- ADORESS (Z � VALIDATION
wi�h tomply w��h suth provisions or Ihis permil shall 6e �f�7�CY.� NO��p�-(��S ;
deemed revoked. CONTenCTOR
IICENSED CONTRACTORS DECIARATION ^/ ���'
ADDRESS Q B�C0.C �II G,{ SI � NO. I
I hereby ofiirm�hat I am licensed under provisions of Chapfer 9 Q� � ��� S �
(commencing with Secrian 7000)of Division 3 0l the Business �iTv �/ f_7u�✓ Cu�SS G "..Q
ond Proiessions Code,ond my license is in(ull force and effecr. ��RipiiON OF wORK "
C FINAI �� � J,rj�
Lice�se Number U Lic.Class� SWIAMSINGPOOI � DA7E � ✓
e� SPA � � �r• • • s 2�
Conlra[lo Dot FINAL }
� I am exempt�n e Sec. ��EFT. O sY � • •5 L.S� �
U
• • B.BP.C.for this reoson �� EIECTRICAI ` " "F G�I �: O
Do�e: - -- � �� O� 0&2 5—�� F—
— Steel 8 Conduit Bonding . U
SignoWre Conduits,Condoctors,Equipment �' � W
� SINGLE FAMILY �"
HOME OWNER-BUILDER DECLARATION � pIUMBING �� .��� ' Z
I hereby affirm Ihat I am exempl trom Ihe Conlraclor's License Z9�
� Law iar the follawing reason(Section 7031.5,Business and p-Trap � -
ProfessionsCade): GasSysiem „l�c,r C-��-a-SU�G
� I,os owner of the properiy,will do the plumbing and Anii-Syphon
electrical work.I,or my employees with wages os�heir (7�%c'N«.S
sole compensa�ion,or o licensed conlraclor will do o�l MECHANICAI
other work ond�he structure is not inrended or offered -
tor sale(Section 7044 B8P CodeJ. Swimming Pool Heo�er �� ,
CONSTRUCTION LENDING AGENCY
I hereby oifirm that there is a constructi�lending agency for Ap���N i� ( TE�. ► �� 3����
ihe performance oi the work for which ihis permit is issued pRINi �S Np.
(Sec.3097,Civ.C� /// �i• • • e c j
lender'S Nome �-d+�++'� � ADDRE55 i"�• � o � ��,[I U
Lender i Address��� �(+ a `�� U` • . � `f-�;�T
V.C.Fee S v z.p Perm�t Fee • ' �'
1 certify ihar 1 have read this applicaiion and sta�e thot the
above inlormotion is correct.I agree ta comply wilh all County � `L� 0 G.O L-c F
ordinonces and St lows relating to building, eleclrical, Issuonce Fee
methonicol ond mbing mnslruclion,and hereby aulhorize ��•esegonon Fee
representati� of �his County to en�er upon ih above• Toio�Fea �
mention roperly For inspeclion purposes.
" ZS
Signawre ol Appl�cont or Age�t Doie SEE REYERSE FOR EXPLANA70RY LANGUACE '
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