HomeMy WebLinkAbout0870A 0911A •• WQRKE{2S'COMPENSATION DECLARATION •.J/// 7� �
T
I Fiere6y affirm that 1 have a certificaie of consent�o self APPtICATION fOR COMBINA�ION SWIMMING POOL PERMIT
insure,or o ceriifiw�e of Workery'Compensation Insurance,
or a certified mpy thereof(Sec.3800,Lab.C.)� 76qppg
CE87fi(3/84)
Policy�vo. Company COUNTY OF LOS ANGELES BU{LDIPIG AN�SAfETY
� Certified copy is hereby furnished.
�Ce�tified co �s filed with the c t boildin m er FOR APPLICANT TO FILI IN BUILDING
PY Y 9 SP ADDRESS
tp�on departmenl. �����
6 -I S��7 ADDRESS IOCALIN
Dnte Apptican /� NEAREST � p�
CITY ZIP 6 CROSS ST. C E. /1 ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPEhlSATION INSURANGE f 51�� ASSESSOR t
TRACT �- 6 !OT LOT NO. (p Mp.p gOpK PAGE PARCEL
(Thi�wcfion naod ncT b�coenpletad N thr pwmil is fw one TEL USE ZONE nqar
hundrod dollors(s10p)or Iv��.) OwNER Np. ..� �. ��u��
I certify that in ihe performance of the work for which�his ��' SaECIAL
permi�is iss�ed,I sholl not employ vny person in any manner ADDRE55 CON�ITIONS
so as fo 6ecome subject to the Workers'Compensot'ron Lows. DISTRICT STAiIStICAL CL455 NPE pRpCE55Ep gy
CITY ZIV CONST. A
Date Appli[anf ARCH47ECi TEL 1 Q C��. ar��l
NOTICE TO AGPLICANT: If, ofier making Ihis Certificole of ENG�NEER Np - 3
Exemption, you should become subject to the Workers' 7t • VAIUATiON
Compensotion provisions of the lo6or Code,you�m�s�forth- ADDRE55 (/
with comply wi�h s�ch provisions or this permit sholl be 7Ei.�} s//j �0[�� YAIIDATION
deemed revoked. CONTRACE NO.`T C/
LtCENSED CONTRACTORS DECtARATION �K�
I hereby affirm ihat�am licensed under provisions of Chap�er 9 A��E� S /
(commencing wi�h Section 7000)af Division 3 of ihe Business ��� �-5�
ond Professions Code,ond my license is in full force and effect CITY C�ASS
/� DESC I pF WORK FltiAl �+p /�
license Numb � Lic.Class� SWIMMING PO�I DATF — 7�r � c lj Ci 7,Q n
Contrac - -� Date " ��g� SPA FINAj.� n• • • •�1 U
5(7.FT. aY�'J
� 1 am exempt under Sec. S�zE �.v ' � �([�r�C� �.
8.8P.C.for this reason EtECTRICAI A �- �
.,x'/ � �p�ln� � . • �::-.Y v-`��; � i
Dote: . . ��� �+�. W
Signa�ure S�eal&Conduif Bonding Z q �Q� Ci'��7 p„�
Condoits,Conductors,Equipment '��6 I z
$INGLE iAMiIV
HOME OWNER-BUILDER DECLARATION MUMBING �
1 hereby affirm that 1 om exempt from Ihe Con�ractor's License
luw for�he following reason(Sec�ion 7031.5,Business and P_T�aP �
Prafessions Code): Gas Sys�em
� I,as owner of the property,wiil do the piumbing and Anti-Syphon
eledricol work.I,or my employees wilh wages as fheir
sole compensotion,or a licensed coniractor will do all MECHANICAL
other work and the slrucfure is no1 intended or offerad
far sale{Sec�ion 7044 B8P Code�. Swimming Pool Hea�er Q
CONSiRUCTION LENDING AGENCY ,
I hereby offirm that ihere is a construt�ion lending agency for TE�
the performance of ihe work for which this permi�is issoed �pg�� NO. � �C G �.� A
(Sec.3097,Civ.C.).
Lender's Name �� � � � �3
ADDRESS
Lender's Addrese , �'�p I � � 7��G
I cenify Ihoi I have read ihis applicalion and stare thot ihe P��'Fea E Permu Fae V' � � ' �Jc Jc�`
above information is correc�.I ogree ro comply with all Counry ,O,�Q Q�� �7
ordinances and S1ate laws reloting to 6uilding, elecfricol, Issuance fee Q.-
mechonical and pi�mbing construction,and here6y authorize ���a:rgar�e�Fae
reprc�s3ntoti�es of rhis County io en�er upon the nbove- ioeol Fae ,
eo�ioned ,roperty for inspecfion purposes. �
L_._ _�s�-/�-�� I
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