HomeMy WebLinkAbout1275A (4) ' � 'JJORKERS'COMPENSATION DECLARATIDN �
, I hereby aff��m �ha� � ��a�P�,�e��;f����e of���5e��}o s��f APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
I fnsure,or a certificate of Workers'Compensation Insurance,
� or o certified capy thereof(Sec 3800,Lab.C) 76qppp . �
I CEHI(i1;t784]
Policy No. compa�y COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cortified topy is hereby furnished. p
1 � Certified[opy is filed with ihe munty building inspec- FOR APPI.I'�:ANT TO FILL IN , qDDRE55 �D � " ''^•' r .�
tion deportment. BUILDING � :.� ', � /
� ADDRESS f;.,",;Ci ^����j�.i;r;' /'I�Ji'Ari� ��'Ci° LOCALITY '�.
Date Applicant ..-� i , NEAREST
CERTIfICATE OF EXEMPTION FROM WORKERS' Ciiv 1 ��H-�i;� ��`i • %�r�i' ZiP : fY+'�� Cao55Si
� `SIZE OF � /� ASSESSOR
i COMPENSATION INSURANCE ;:{'-I,�F'
TRACT: ('_, .� LOT I.OT NO. " ;X MAP BOOK PAGE . PARCEI
(Thls section nead nof be completed if 1ha permk is for one _.. � , 7EL r ,. .t15F NE MAP
hundred dollars(�100)or less.) pWNER �'r�"l•`�k" i s���:p{�';: NO.�.�� , �i¢y� �� NO. �y •��'3-
I ceriif that in ihe erformnnce of�he work for which ihis ,,p+ - ' SPECIAL
permd�s issued,I shall not employ any person in any manner AD�RE55 .1.(}`�1` 3��,/!�^n'/�V l(2�//1�,t-�f'�L� ��'U� CON�ITIONS
so as�o become subjecf to the,Workers'Compensation Lows. �-� ' y� _ OIS�RICT STATISTICAL CLA55 TYPE PROCESSE�8Y
CITV,S�;',r�/i'I% �, � ��ZIP •j � _���C-..y �O CLASS NO. � CONST.
Date Applimnl ARCHITEQ OR < _ iEL y'�
NOTICE TO APPIICANT� If, after making this Cerfifimte of ENGINEER ;�/- �.�L�/L �.�'w.� NO.
Exemp�ion, yau should become subject b the Workers' �. /j, �,�i;� � VALUATION
Campensnfion provisions of ihe Labor Code,you must forth- ADDRESS"� `�^ f�-._I .��� '�� ✓'
with comply with wch provisions or ihis permit shol� be -�t �/ - Tft,��.�, ; VASIDATION
�`.>�� 0�15 t17'7
deemed revoked. CONiRACTOR _>f�.)_-, F;�S�.'% NO.i_l/�'''�
I IICFNSED CONTRACTORS DECLARATION ^�� -_ � _ IIC.
� ADDRE55./�.•�"? �f— i��l�jC.% !J NO, r'
� I hereby affirm thpt I om licensed under provisions of Chapter 9 �ry ��� j �� � � ���F4
(<ommencing with Se<tion 7000)of Division 3 of the Business �i7V�n��e �,�'y,� ��'�'�= CLA55
I nnd Professions Code,and my license is in full force and effed. pESCRIPTION OF WORK � � �}o a o �c�1
� fINAL
� License Number Lic.Class SWIMMING POOI ❑� pptE ► � a °�J 2:�6
IConhacfor Date SPA �` FINAL �' o ¢��.:;�� U.
❑ SQ.Fl. ,� eY U
f i�m exampt urde�s��. sizF ��7� `t 1�" n 7.1 '1 —8 5 �
IB.&P.C.for this rr.nson ELFCTRICAI �
oa�P e l �,� a
Stee�&Conduit Bonding
� Signoture Conduits,Conduclors,Equipmeni � p���J z
SINGLE FAMI�Y p�C �.
HOME OWNER-BUILDER DECLARATION PWMB�NG
I hereby affirm thot I om exempt from ihe Coniractor's License
Lnw fo�ihe fnllowing reason(Seclion 7031.5, Business and P_r�pP � ,
Professions Codej:
� Gas System
� I,ns owner of the prooerty,will do the plum6ing ond Anti-Syphon �
elecirical work.I,or my employees wilh wagesos their �
sole compensation,or a licensed coniractor will do all MECHANICAL ^
o+her work and the str�clure is not intended or offered t ' . ` �L..
for sale(Seclion 7044 B8P Code). Swimming Pool Heatar Q �� (�
CONSTRUCTION LENDING AGENCY C�^�.}�
I hereby affirm Ihat ihere is a consirucliori leriding agency for APPLICANi � TEL r^ � � � \ ��
ihe performance of ihe work for which ihis permit is issued (pRINT) }� �,j � ����/�� NO., "{� '��� � ��`Y '��, ``
(Sec.3097,Civ.C.). ' r .
lender's Nome ��,% L y�// J ) �
ADDRESS�'�.("�'�' 'fJ:{-Cl�� LCF1i��I4� �
Lender's Address P.C.Fee 8 �/"�"s �O Permd fee
I certify thot I hove rend rhis application and stote Ihat Ihe
above informa�ion is corred.I agree to mmply wilh all CouMy
ordinances and Stote I�ws relatmg to building, eletlrical, issoanceFee
mechoniml ond plumbing construction,ond hereby authorize Investigaiion Fee
represento�ives of ihls County to e.nter upon the above- Toml Fee
mr.ntionc:d properly for inspertion purposes.
Siynnw�e nf qpp6n,m w Aqem Dare SEE REVERSE FOR EXPLANATORV LANGUAGE �'
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