HomeMy WebLinkAbout1556A (438) • •-- WORKERS'COMPENSATION DECLARATION �
I hereby affirm that I hove a cert�fimte af conseN ro xlf
insure,or u cerrificate of Workers'Compensa�ion��g�.a��e, AP�'LICATION F4R COMBINATION SWIMMING POOL PERMIT
oi a certified copy thereof(Sec.3800,Lab.C.) 7sn2oe
cee7s�3rea�
Pol'rcy No. Company COUNTY OF LOS ANGELES BU{LDING AND SAFETY �
� Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Q Certified copy is filed with ihe county building inspec- ADDRESS 3
tion deporlmant. ����� /�
�ate �/��F' � j y�is� ADDRE55 7 W(`Ld��C/� IOCAIItV �L 1.�
Applicant ,..,s �7
Ct7Y L//�� ZIP I/ �� �RE57
CERTIFICATE OF E%EMD710N FROM WORKERS' cRoss 57.
COMPENSATION INSURANCE S�ZE Of ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This udlon rwod nof M eomplet�d if tho pwmll h for ono TEL. /tl ^f 6 USE ZONE ��P j b g � 3 a
hundrad dol6nn(i100)w I�s�.) OWNFR �, ryp.J(,S �`' ryp.
I certify ihat in the pe�iormance of the work for which this gpE�i,q�
permit is issued,1 shoH not employ ony person in ony manner ADDItE55 / � ��Q CONDiTIONS
so as fo 6ecome subiect to the Workars'Comp�nsotion laws. � DIS RICT STATISTICAL CL455 TYPE VROCESSED BY
CITY (rll��,/ Z!P �� C��. CONST.
Date A IiwN ARCHIFECT OR ' TEL /1 �y�
NOTICE TO APPIICANT�PIf, ofter making this Certificote of ENGINEER , e r�r�r�ml NO.v� �' �3 � � a� y�`
Ezemption, yau shovld become subject Io the Workeri p�pREu VAtUATION •
Compensaf�on provisions of the Labor Code,you must forth- � , ' ��"" ^� VAUDATION
wi�h comply with s�ch provisions or lhis permil shall be (/ TE�� �7 f�
deemed rgvoked. CONiRACTOR �! dd� - �+10. �d �� ; ` �
LICENSED CONTRACTORS DECIARATION ����
I Mereby aftirm tFwt 1 am licensed�rtder provisions of Chopler 4 ��R€� �@F¢ `�L�p t �� _
(commencing with Sec+ian 7000)of Division 3 of the Business dTV � �LlCi�fly7 �M55 �^S'
ond Professions Code,and my license is in full force nnd effect. ��RIPTION OF WORK � .
License Numher S d�/S� ���.Class C` �^3 SW MING POOL � OA Et � �� }
�� � �
Confractor������a'4�S Dafe �%'�"�7 SPA � FIlJ
� I am exampt under Se[. �ZE sY ' , -� �}'''�j � �
8.8P.C.for�his reason EIECTRICAI �� .� . • .���a �, a � �O-, fi
Qote: � � ��,y�j �
Signature Steel 8 Conduil Bonding � a s E , - N �
Coaduits,Conductors,Equipment -. r' Z
SINGIE FAMILV �., ry ���� �
HOME OWNER-BUIL�ER DECLARATION PLUMBING �
I here6y affirm that I am ezempt from the Convacror's license � �
law for 1he following reason(Sectian 703I.5, Bu:iness and P-Trop
Professions Code): Gos System
� I,os owner of the properry,will do the plumbing ond Anti-Syphan
electricol work.I,or my employees wi�h wogee as lheir
sole compensation,or a licensed controdor will da oll MECHANICAL
other work and the ehuctore is not intended or offered
for sale(Section 7044 BSP Code). $wimming Pool Heater �
CONSTRUCT�ON LENDING AGENCY
1 hereby affirm tha�the�e is o mnstruc�ion�ending ogenty for
ihe performance of�he work tor which this permi�is issued AP�pR M) �o� �RU f� NO. . P �� ��� I
(Sec.3097,Civ.C.). �
Lender's Nome AO�RE55 Q e � � .J�..5� /� Q�t�/' h�L I
Lender's Address `
P.C.Fee S Permit Fee ?� �
I certify that 1 hove read Ihis application ond s�ate that the
obove informotion is correct.t ogree to comply with oll County ^ v
ordinances and Stale lows relating to 6uilding, eleUrical, luuonce Fee
mechanical and plumbing conslruclion,and hereby authorize ���esrigaiion Fee ��.�
reprasentatives of fhis Couniy 10 enier upon 1he abave- Toml Fee
meniioned roperfy r inspeclion pu�poses.
�
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