HomeMy WebLinkAbout0956A 1015A (9) , i
WORKERS'COMPENSATION�ECLARATION 1 'I
I hereby arffirm lhot I Imve a certificate of tonsent to self � I
insure,or o cerxficot�,of Workers'�om���„o���5�,a��e. APPLICATION FOR COMBINAT{ON SWIMMING..P00! PERMIT
or a certified copy thereo��(}Sec.3800,La6.C 7a�2oe -�-
P\��Gl y-C`1�ip�� �� CEB7613/B4) . . .
rrty�ote:_1--��Lomp ny �� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerrified capy is hereby furnished.
FOR APPLICANT TO Plll IN eunuir+c
Certified copy is filed w'd ounry building inspec- q0�RE55 Z�3,S �1:?yp �C�/
fion depoC'r�ment. BWIDING �� `�yf� ��5�� t�,A
Dote �_`'o� APPiicam ADORE55 "L V�� IOCALITY 1�A,Q/.1� �,.
CITY bl�rIONP �� ZIP NEAREST
CERTIFICATE OF EXEMP?ION FROM WO CROSS ST.
COMPENSATION INSURANCE ��0� SIZEOP ` � q�Sg,pR
TRAC� � l0T lOT NO. \D AAAP BOOK pp� pp��
(Tht�wefion ncad not b�comploNd if fho pfrmll�is for ona TE�. USE Z�E mqP �h O #
Fundnd dollan(5100)er lass.) OwNER " r� NO. ff� ( NO. d..
I certify�hot in�he performance of the work for which this �('�� � V�n� ��� �
pe�mit is issued,I sholl not employ any person in any manner ADDRE55 �.4 35 U��� W(�+c �� w0 CpND1TION5
so os�o become subiecf to the Workers'Compenwnon Laws. � 4� ZiP oisrQicr STATISTKAI CIASS TvrE paocEsSeo ev �
an GONsr.
Date Applimnt ARCHITECt TFL. �5 �
NOTICE TO APPt4G4Nt 4f, after makinq this Cerrrficate of ENGItaEFR /�.��� p�p. � � �
Exemption, you should 6ecome subje[t to Ihe Workers AppREu+'���-�P�C�LC V1N NV � YAtUAT10H
Compensation prov�sions of the Labor Code,yo�mus�forth-
wilh romp�y with such provisions or this permif sholl be TEL s �`l�I•ffV ��r VALIDATION
deemed revoked. CONTRACT l.V�.0 Npqjq ��'�
LICENSED CONTRACTOR$DECLARATION ��� 1 "��
I hereby affirm thaf I om iicensed under provisions of Chapier 9 '�DRESS� � 'z..._+ti� NO. N s �
(commencing with Section T000)ot Division 3 of the Business �J � 1��� _
ond Professions CoAe,and my license iz in full force and eHect ��TM
�,1��t� DESCRIPTION OF WORK • �^�� � �
License Number lic.Class C� Syy�µµ��ppp� � FINAL /_
'C GAi! p
Contractor�k-1dw/��'J Date `^`�' �1 �A FINAL� �
❑ x.�.rr. ``l� er �- t
I am ezempt u�dar Sec. SRE "�
8.8P.C.for this reoson El€CTRICAL �, C�H ZsbQ�— ��'��5.r'4i, V �
Date: , — '1 . � � {
Steel 8 Conduit Bonding ' ff� � � ��1 � �
Signot�re Conduits,Condoctors,Equipment ('� ' • ��f:���; U #
SINGLE FAMIIY ?^ .�� �&��,,,c;i r_ Wa 1
HOME 6WNfR-BUILDER DECLARATION pLUM81NG v � N
I here6y affirm fhat I am exempt ftom Ihe Controctor'a License ^ Z
Law 4or the following reason(Settion 7031.5, B�siness and �/� 1 � �
Professions Code): P-Trap
Gos System �� ��� I
� I,as owner of the property,will do the plumbing and AntiSyphon �
electrical work.I,or my empioyees with woges os iheir
sote compensation,or o licensed contraclor will do all MECHANICAL
othe�work and the sfructure is not intended or offered I
for sale�Setlion 7044 88P Code). Swimming Pool Heofer -
CONSTRUCTION LENDING AGENCY �� C 1.�,y '
t hereby affirm Ihat there is a tonstruction lending agency for �
APMICANT TEL.
the�performance of the work fo�which ihis permit is issued (pRIM�. ryp, �'JJ �• ` • • •3
tSet.3097,Civ.C{.).
lender's Name q�(�j��� AppRE � � J� (�C3V� � 'L C'u.S�
. . . . . . . . ...._..__
Lender's Address ! ' ' °��'`--'�'���
V.C.fee S Permit Fee !�Q,w - - - J
I tertify�hal 1 have read ihis applicafion and state that ihe - , Q� '� �'j—��;
obove informotion is corred.1 agree to comply with all Couny �6 5'� -
ordinonces and Slote lows reloling lo building, elactricol, IssuanceFee
mechanical and plumbing construction,and hereby authorize Investigation Fee �j ^' r
r esantotiv of this Counry to en�er upon Ihe above- Toial Fce ��v 0�V v
' ned pro erty for inspecfion purpose I �
t �, f
��.e f Appliconr o a �r oarc SEE REVERSE WR EXPIANATORV LANGUAGE
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