HomeMy WebLinkAbout1097A 1838A (5) �
WORKERS'COMPENSATION DECLARATION
I hereby:�af�;,m ihat I have a certlifcote o�cansenl 10 self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � ;
insure,or a cerlificate of Workers'Compensation Insurance,
or,o ceriifie copy ihereai(Sec.3800 Lob C.) -- �6a2o5 �
Policy No.�Company(��Oi�l � CE818�3/8d)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Gerlified copy is hereby furnished. :
FOR APPLICANT TO FILL IN Bw�oiNo S c
Cerlified copy is filed with Ihe county building inspec- A�DRESS i
tion depor�menl. BURDING �
Da�e��/ ADDRESS IOCALITV
_u(�Appliconr
CERTIfICATE OF EXEMPTION FROM WORKERS' ��rv Z�p C�RO55 ST. l O'l� O �-2�u�rvs
COMPENSATION INSURANCE p S�ZE OF A$$ESSOR
TRACT Q l07 l0T NO. MAP BOOK VAGE PARCFL
(This f�etlon nNd not b�cemplH�d fF 1h�p�rmlt It ior on� TE�_p USf ZONE MAP _
hundred dollor�(SI00�or Iou.) � OWntER N0. p��— Np. �� 3�
I certify tha�in the perPormance of the work for whicn�his .�, el SVECin�- �
permil is issued,I Shall nol employ ony per5on in any manner ADCRESS I IV`� � CONDITION$
so as fo 6ecome subjecl lo the Workers'Compensalion Laws. DiSTRICi STATISTICAL CLASS TYPE PROCESSED BV
CITV 21P CtA55 NO. CONST.
Da1e Applimnl ARCHITECT TEL ' `O �` 1
NOTICE TO APPLICANT: If, ailar making Ihis Cenificale of ENGiNEER NO. ` \
Eaemp��on, you shoold become subject lo the Workers'
ADDRE55 VALIlAT10N
Compensa�ion provisions oi the tobor Code,yoo must forrh- VAIIDATION
with comply with wch provisions or Ihis pPrmit s�+all be TEL s �/�(�
deemed revoked. CONTRAC�OR NO. (�/
LICENSED CONTRACTORS DECLARATION ����
I hereby offirm tho�I om licensed under provisions oi Chapler 9 aDDRE NO. f
(cammenting with Section 7000)o(Div�sion 3 of the Business '/1 ���� �
and Professions Code,ond my license is in Fuil force and eHect. ��TM r�' M55 �
�/���y� DEXRIFTION OF WO K
Litense Nomberi�"r�/t;/ lic.Closs�� F1N�l , `� �+(�.7��
SWIMMING POOL 1�--�/ DATE / `�
Conlractar (,L�1/� �O ��e�_ �E T �D U fIN � � e e 8 Q�J d
� I am ezempt under$ec. - O
8.8P.C.for Ihis reason �, n � (� • e a£� !�� U
EIECTRICAI �r,�� �YT_`� � �
Da�e: . l��- O H 2 U—f�� O
$ignoNre $teel R Conduit Bonding ����^ �-.
Condui�s,Conduc�ors,Equipment ti V
. SINGLE FAMILY a
HOME OWNER-BUILDER DECLARATION PLUMBING � t/)
I hereby aHirm ihol I om erempt{rom the Conlroctor's Utense � Z
Law for the follawing reason(Section 7031.5,Business ond P.irop
Proieuions Code)� Gas Sysfem ' �
� I,as owner of fhe ro er II do ihe lumbin and Anti-S hon �`S�' f�� �
P P N,w� P 9 YP �
elec�rical work.1,or my employees wilh wages os iheir (�
sole compensofion,or a licensed confrocfor will do all MECHAN�CAL ?�...1 S `� F,J.L�i
olher work and Ihe slruclure is not inlended or offered /��\
for sale(Section 7044 B8P Code). Swimming Pool Heater � E'�- "' «"'� �` � � ° ° "v
CONSTRUCTION LENDING AGENCY � I •G O O.J�
I hereby afFlrm that there is o construtlion lending ogenty for APp��� � TE�
Ihe performance of the work for which ihis permit is iss�ed (pp�Nt � , � � . e .�G��`n�
(Sec.�097,Civ.C.). �
lender's Name aooaess � D 9.2�—f3 c3
lender's Add�ess p.G Fee f �7 , rmu Fee Q.O� �
I cerlify thot I hove reod Ihis opplim�ion and stole thot Ihe (�
above iniormation is correci.I ogree to tomply with oll County ��•' I S Issuonce Fee �O�O �
ordinances and Staie laws relating to building, electricol,
mechonicol ond pium6ing construction,and here6y outhorize ` �^°estigo�ion Fee � _ .
re resentatives of this County to enter upon the obove- ioml Fee Q Q Q
ien rop�rry for inspeclion purposes. � �
� �� ��7y-��
Stg����e of AppGmm or Agenr pote SEE REVERSE FOR EXPIANATORY UNGUAGE
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