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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. 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