HomeMy WebLinkAbout1461A 2133A (221) I � � ������ .
WORKERS'COM7ENSATION DECIARATION \ � � � - � � ' �� � �I
I hereby ofFirm'�?��have a certiFicoie of�o�5e���o self � APPUCATION FOR COMBINATION SWIMMING�POOL PERMIT u
insure,or a.tee�i{��ejt.,(Workers'Compensaiion Insurvnce, I -�
oi o certifie c�py the�eof(Sec,380D ob.C.J �76naoB - � �� -� � � � -- �•' • ' � � �
� CEB]6�Jl8��
Policy N OS �ompony U� �� COUNTY OP LOS ANGELES •, BUILDING AND SAfETV
� Certified mpy is hereby furnished. �
� FOR APPUCANT TO FILL IN eunowc
Ceriified copy is filed wilh the county building inspec• i ADDRE55 �i� �L�
tion d part ent. n BUIIDINGu L — -
Dale j� Applicdnr•�� ADDRESS� /b� Sl� � NOfAEN ' �GYi�--
CERTIFICATE OF EXEMPTION FROM WORKERS' � GiTV .Zia _ CROSS 57. - 1 %� GT•
� COMPENSATION INSURANCE SIZE OF ASSESSOR
TRA�T Z' l0T. LOT NO. � MAP BOOK PAGE PARCEL
(Thts sedlon n�od nof ba compl�t�d II fhe pnmll is for oee TEL. USF ZONE � MAP � . � -
hundrad dollars(S100j or lats.) ' OWn7ER NO,�f L�' �b 9 p�p, ��3
�I certify thal in the periormance of the work for which this -�� SPECtnL - � -
permil is issued,I sholl no�employ ony person in ony manner ADDRE55 (i D CONDITi0N5 �
so as to 6ecome su6ject to the Warkeri Compensation Laws. � ' DISTRI�T STATISTICAL CLASS TYPE PROCESSED 0Y
CITY Q.` ZIP �J 7�.S! CONST. �
Dale �AppiicoN � <RCHITECT OR h� / QASS NO. p
NOTICE TO APPLICANi: I!, ofter mvking ihis Certifitore of EUGiNEER � NO. /� d-� _
Exemption, you sho�id become subjec� to �he Workeri � � � VAIUATION .
Compeniation provisions of ihe Lobor Code,you musf forfh- pODxE55 . � �
TE�. VALIDATION
with comply ilh sucb provisions or this permit sholl be CONTRACTOR NOG�2��3�Y s �� �DO
deemed revoked. � _ . .
LICENSED CONTRACTORS DECLARATION 1 uC. � .. �
aDDRE55 3�S7 � No�{3�YP7 N � �1 tt 6 1.A
I heieby affirm rhol I am licensed under pro�is�ons of Chap+er 9 I �i� -S -� � � �
(commencing with Sec�ion 7000)of Division 3 a(�he 8osiness C�TY � 9/7J0 CL455C—S3� , � '
nd Professions Code,and my license is in full force and effett. . �° • • �2.3
'J CESCRIPTION OF WORK FINAL /l��J
License Nu e._ 7���7'� ��c.c�oss e S 3 iSWIhV,11NG POOL - -.. . �^ DATE ,/ /�'�� � � 1 + •4 8 8 8 ' �.:
��/f �_ 1�` SPA. . . - U FINAI. � • o o G�S.a H� U
CoNm o a Dote
SQ.FT. 6Y :
� I om eaempf under Sec. SIZE G - . . . .- ��� �Q� �`8'] O
B.BP.C.for this reason 1ELECTRICAL � - � ' V
Date: � . .. W
S�eel&Condui�Bonding n-�
Signolure Conduits,Conduttors;Eqoipmenl � � . � Z '
SINGLE FAMILY . . . . _
HOME OWNER-BUILDER DECLARATION ,GIUMBING . - �
I hereby offirm ihal l om ezempt(rom the Contractor i License .. � . � '
taw for rhe foltow�ng�eosen(Sec�ion 7031.5, Business ond P_T�aP - . � -
Professions Code):' Gas System . . � . �� ��
� I,os owner of ihn prope•ty,will do thc plumbing ond ANi-Syphon � � . �� .._.. ,
eleUrical work.I,or my employees wi�h woges as their . _ . �- �� � � -
sole tompensation,or a licensed contractor will do all :MECHANICAL . ' �
o�he�work ond ihe strutr�re is no�intended or offered . �� - � � �
for sale(Section 7044 88P Code�. i Swimming Pool Heo�er � �� �� � , � �P� a J A
CONSTRUCTION LENDING AGENCY j . _ Y s� � ��3 � �
I hereby oifirm that there is a conshuctian lending agenty{or , .
�he performance of ihe wo�k(or which this permit is issued . AP�pgjMT / ��' �s-G3�� �
(Sec 3097,Civ.C.). ( � f./ 5 i / - NO.� . . . � • � 2�S�
lender"s Name ADDRESS.��'S J SC'/�//9(' P/� �,C (�//�/�'� ,� -. - . . . � N � 2 5'5`/V
lendei s Address ' p (� ` � . - � 0 9,2 5--8 7
P.0 Fee S 6�5� Permi�Fee -� . � � � �
I cerlify�hot I hove read this applico�ion and sfate ihat the , . .
obove informa�ion is coneU.I agree to mmply with all Coony - lO � " " " ., ,
ordinantes and Sto�e lows reloiing to buiiding, eleclrical, IssuonceFee
.mechaniml and plumbing constrodion,and hereby au�horize i��esrgaro�Fee � � ' � - . �
represeniotives of this County to enler upon the above- Taral Fee
menlioned p�operfy for ins clion purposes. �, . .
� . �� 9—io��-j �
S�g�o�v.e of nppccan�o.ngeni Oa�e ; SEE RFVERSE FOR EXPLANATORY LANGUAGE � /
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