Loading...
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 ' , - "..�i't u'� � .c= � c '�c. . s � a � o o E� c.� ° � " " '�� °. — -- - - � . ,o • ,�� 4 .. Q c .� - c -� ° � �.c` ^ + I i : ^..,c-_ a � o '� Qb > .. �: y�- _ . � o `.� � � i 4'� r ...p T � ��c u � j C�n '_, N �U O C ;� T Q o o j � --- �' . ..� .. � + '' � �' F C c° {_'G Z� � �L ', � C ri ,,,� E n n ��'� � �r V L':� U _" .:l 'I i.—" � '= ;; �o"c c o ` c, o s �>' c t 3 0 � c c � . � i v:i.,'o i; _ ..�, o� »� � c: �`o-c �„� - _ '-� ° c a ,�� { ' � •' 7 v: � j [ .L:'F'.�„ C C u . . G �. 3�� �:' L � `v~ � �+. t . O 1 . � C ` � C c..� ` � o c � �C ° o �.p -.` ° F ` � c:.1.c � '� � • j ! . �"j ._, y' — � .� �v "� � I s� ' � c�w�a E._.� r`'� °o �= E-" ° �'-��=' �„ o � iv�° 3 � w � i i . / i ! � `;C' '� . C t _ ` . 'DU O�'� ^-� `--� . t� - w I i Q ... �, a • � - P¢ a ? � � � �. 2 ` n '" r�- � ° : �� .. c�U c_ t" _ . • � . '; • ' c c ' _ ° � �� � F o` ...c a� ' E . 'lL � o c N � ;� _ . _ i _.� � I �f"I � G:�< � E �= � u � . �: c.c �- o m c � i c �.^, � � �, c�- � . . � , G c�C T p 4 � �C7 a" C 6 C C: '� C � 6� o c � ,•` c C O u ` yf 'i' :_I ' 3 c c� c E a o c� � � :t; a 2 � '� 4� u� .• �,' � � w c o o ; r. ` v c c c � c 3 c , � ` ;,^ ,.: c o o c o - ,n �, p '' - . .:f I . U E�U N L N ` C N o`o _ � �-o v o? G` _ �, �'� c. c N � � , � - c �- :-f � - � -- c o c ° l�� „ '- E � =. 't E c � o� � c c��_ — ° L' C c ° � - _i. O, i i I ;1 �'� I i - - U l� ;,� C G O _ � � C � � i. (:� ` [: p C � '^ I � I . . C C� � � u . r N..>S x .� n ' U C � b N C � '� t� f V v. C � �.+ - - _ . 'f . I w s:• .G � �•a C �a m - u � ,c >. � r c` r. ��c o Z' q'� - :-�' ' I /i� ,I .. p . � 4�[ u r C Ll �• � � U O C_ � J G , � � �• c ? ��� .c,i� � L .� � �^ .e � O � O�--� C � C.` .0� G }' a. ',� p ' % � i I I . ' � . � l .. � ui T L O L � (?� � l r� i '1. • " C „_, 3� � .^�� O-C�� �P C � U n..._ C.1 G �± =�� (J C O C'-'y.v� (J V ` ` . '� ..� , .J '� I - ' `7 ,�O C O U ' V Q� U >,O` (7 ^ 7 O .� C U p = w C�l . U _ � I . ' . T �^ �� O � O -O �- O u o. � y� U � J N � 't"G . O j . � •.� I b O�a. j C ` "� � U � C `�� OVO `n � �❑ � „ ��7. O jC� G � .CiC❑'� �i �LG� ❑; V j. . I I I ' r"�'.N �� � ��O U C�O O C C� � U 'E� � O C: 7 � ' 'Jvi i: C � �^ � U n - ' . t I /�j .. -.' c G C�'U vi m r� v� 3 cL �. � G� ._. C. L" " ' '. � G I I i - •I { i. , ._ , � . . � . , . ' fl N � �. . . . . � .. __ .. . � � l_ . _ i 1 . .j � -, . I , . . l . . � : . � � _ . �� _ � , � . _ ; _ ; ,; _ :, ;;; ; : �.,i . . - , - � _a� ( �, W • I ={: �,1 , .' � � � '. i �-�� � n . ` .. - ,�r , ' . �� - L . � '� ..�. i . _ _` � � • � ' ' � " ' • 0. � - , . ' i N , ' , �' �_ - I_� ' � . i /" . ' � 1 �/ -.� _ '1 1 ' . � , �- , ' � ; � ; �.: � ;.i ; �, • � -' � � " ; , ; � ;` �., : ;,. ,,, : i ; �. � . . . . � � � � � � � > . � Q i . . O ; - �: . G � �' •i � N _ � :�� � . _ . ;�. '� ��, 1 V C- � � I I J I �� � i � I i - � f I � _ �fL d � � • " ' _'" . '�"`"�. �. � ' Q - J ' 1J � � �� N �� i Oi � � ` J _ ^' � � \ � � I ' � �. (Y�+ `u � --- � l. _ " -" eJe �� � � ' � O� � ° � � � Q U� O w i � I v N �' \ � N F 4.LL. V V F- � � n' f I 1 W �: �' '��d ' K � W N � O[ V N .4. ' ' I d ' ¢ O W O l� K � ..y�. O Z� W � $ W �� T �j O� �" Q u. O' U' ' � .,, � t d V V � .� w � I I i I F! W ! Q 0 ..+ W y � N CC W u W '- � � !, Q � -� �F � Q Q W + � 2 Q p 2 W Q p r ' o 'o - — �-'- ' - -V' O O � � r- �n ., m V C� � v� ¢ �u �:. l� uc u. l� a a