HomeMy WebLinkAbout1052A 1053A WORKERS'COMPENSATION DECLARATION �
I here6y affirm thai I have a certificate of consen�to self
inwre,or acartifimie of Workers'Compensation��s��a��e, � -- APPliCATIQN FOR COMBlNATION S.�I�MMING P�OL PERMIT
or a cerfified copy fhereoP(Sec 3800 Lob C.) 76a2oe - '-- - �
,,;/y, CE876�3/B4)
Policy�'9�compan COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerlified copy is hereby furnishe .
FOR APPLICANT TO FILL IN sunoir�• �-
�Certified copy is filed wi�h ihe counly buildin ' spec- AppRESS
�`-� tion eport ent. BUILOING 5
ADDRESS C� C. LOCA�ITY. \f�, .
Dat� ApPlitant , � NEAREST - M
CER IFICATE OF EXEMPTI FROM WORKERS' CiiV �, 21P CR0.5557,
COMPENSATION 1 URANCE '1�r �ZE OF .r� �P e�� PAGE PARCE� �
TRAR „7 LOT LOT NO.
�Thit ucHon nNd nof b�complolaJ N tIN p�rmi4 is fer ene TEI. USE ZONE AAAP
hundrad doNwa(SI00)w I�s�.} OWNER r NO. /J NO. �Z-
I certify thar�n the performance of the work for which Ihis . (�-� ti, SPECIAL
permit is issued,I shol)not employ ony person in pny manner ADDRE ' CONDITIONS
so as l0 6e[ome subjed to Ihe Workers'Compennation Lows. OiSTRICT STATISTICAL ClASS NPE PROCESSED 6Y
CITY ZIP C
��u�.p�
Date Appli[aN ARCHITEQ TEL ,2 ..
NOTICE TO APPUCANT: If, after making this Certifimte of ENGINEER NO. - E
Exemption, you should become subject to the Workers' �� ` � �VAWaFWH �
Compensotion prov�sions of the Lobor Code,you must for�h- ADDRE55 � �
wiih compiy with s�ch provisions or �hii permit shail 6e ' TEL. = VALIDATION �
deemed revoked. . GONiRACTO CG, NO.
UCENSED CONTRACTORS DECIARATION � ��� �D
1 hereby affirm thae 1 am licensed vnder provivons of Chapter 9 ADDRE55 N . s _ '
(commencing with Secfion 7000)of Division 3 of the Business Ciiv J1 CC' �4
and Professions Code,and my license is in full force an'ect pESCRiPTiOtv OF wOrsK` F�� � �
/A' ��j, � �1D52A
licanse Num6e��,7�-�,��tia Clo SWIMMING POOI DA7E ^ a ,
CO(�tfOtl �at[� �A �• ••*C� =�
FIMAt O , �
so.Ecr. eY I . .4�.3� �
� I om e:empt unde�Sec. /� Q
8.8P.C.for this reason ELECTR{CAL � �`T''��- � • � .4 5 3 7= V �
U
Date: W �
9 Steel 8 Conduit Bonding � �2� 5-�i b a
Si naiure Conduits,Conducb�s,Equipmen� j� 1 r� N �
SINGIE AMIIY p�UMBING j ��"- ��`�� z� O�3 i� � �
HO OWNER-6UILDER DECLARATION �
1 hereby affirm tha�I om exempt from ihe Contracror i License / �• • • • i 3
law for the fo�lowing reason(Section 7031.5,8�siness and P � -.�` �/� B�/r �
Professions Code�: Gos System / ' � � �3'C Q �
� I,as owner of the property,will do the plumbing and Anti-Syphon • • � L��j��
eleciricol work.1,o�my employees with woges os their _
sole mmpansation,o�o licensed contractor will do all MECHANICAL 1
o+her work and ihe structvre is nor intended or offered � � �2,� 5-8 6
for sale(Section 7044 88P Code�. Swimming Pool Heater �
CONSTRUCTION LENDING AGENCY �
t hereby affirm fhat there is a construc�ion lending agency for y�PP���NT TEL.
�he performance of the work for which this permit is issued �pg�NT) NO. �
(Sec.3W7,Cir.C.).
Lender's Nome ADDRESS
Lender"s Address p.C.Fee E ��J` Permrt fee !J � `��� ..
i certify thot I hove read ihis applimtion and sta�e that�be . .
above information is mrrect.I ogree ro comply with all County �Q� ��
ordinonces and Stale laws reloling to building, elechical, Issuance Fee
mechonlcal and plumbing construction,and he�e6y authorize imas�igonon Fee /� �` R�
represe ta�ives of t ' ouMy lo enter upon the a6ove- To�al Fee .
me ion d ropery or in eU�on purposes. �
i
5 �u of Applimnl or Agent D e SEE REVERSE FOR EXPLANATORY LANGUAGF - �
� � ��
��� �:- ���
N '
0 �
T�
u 0
. a m s o w a m '" c I , '1
t
m '- o E= o " ° c O a � �J l,
tc� c ° c °' .°. `°-O °'� ` d �
,� c ._m a o d�m�o� a m >s m o o n. °o '
°''c � ^ ° d'v m r � � E N � ' � o � .� � "v �n
L L d .�-L.. � � � v p C d"Y �i N Sl � _ i�� � O Ol � �
o`n' L-`"- o°,° Q,a s v' L'c o ''�a.c `s�-0 3 E y �,v o; �a+ r
�� ;o � c ; _-o ,� � o � O
.� odo..c�c ° '"y'- ErpO = 3� d '"- °' o o �„. oc— z
r C �� N O�v�Ot � D � 6j�C N O N [ y ,� 0�..m. �'O'O p c O � v� CL
4 u � u'w�> E �" ).'O � O C.v� O d � � T•- O C� .
U J u i o n ° E m a gg�� 6? -n v ° N o �.n .a � '^ �n.m ° °' °' �
Z d ° � v a� � o � ; d d a � o °� m o a ° »' tL n 3 �ts c. u
Q £ c ° a N» � � `�> •. m ° d rt-o m °"-a o c c ° c Q o } � ` d 3 y
e.- � o � E « o a m � }E o `o o m m-° � °' a o-O °" n- o o d � O y ' '
� '� _ .- O E . C1� "D 67 C N
� d r�' fJ L Q Q-.- Q-D O O � L d �E 6r m � �� w i u C a
e(�- .c oEco. a o ° oc^tsv o o ss o mo ° v ,
y °' °'� ° � n.� °t ° m � � °'a v c `v °-� o+ 4 � v. � v a-�'� �, � .
� % ;_° `�� ��a' oxia� � LOCOoom�'-�-000, . c `w' � o� � a y ` '
� �Q ' '
� m �u N a � a.; o N c � � � N y, ' • � c y 3 ! 3.:� o '^ � �. .
o � �'o a � d °o ° d �=' ci o � �' '�n.�o ° m'd � d o 0
`� O y N V y O � N•�� m fL G. . G � N d � Q1 N +ti- y n'�O.O j C V � p-O O O Q;
m S � Q ` � U C L T J O_'� O@ �C �, "' L C � O M O�� .�'n L U O O
y s p O � '^ Q_ _J O O 6� p V� 6 N � N d y.L � > � Oi � � �'� L 7 L � O
E �, �
Z d > n_t� w o >-o�-= � y m-°o o �' i ; o-> > o�n,o ; � _
O� ; c o� y o °� ° m n � �0 a� m � ; °'.c � o "n Q � '
0 O a '� ,0� .ti-0 C V�" C O 6 2 NG�1 .di E � CL L
T �^ d LL'� �' C M � 7i
N '^ � 7 y� � C� O•d ��O� �'II
C Q j U�n
L � � m oo'E
�m
i
' � .�
O
, Z .,
O '
W
� �
. �
�
�
a
i
� o -
4 ... W y'
2 J
� �
+ � W
'O
V `� � �� �
4 � � �' t t9 2 O �
� �
Y �^ — Z=, �. 4
pG p '� pr v w Z
< D J �� 2 Y O z p '
.+ ' a . �
a. '
O Z � 'W = y�N i J W Q`' Y
4 A r+ "� � � 4 i +�7 � e'
s s
a O , r . Z �°'�'n �` u � � .��.-
� a
� 0/ `�u 1{ f o _ �i c� �' Z � �, u .
O W F C Z � :! -' Y �' 4 W ,�"���
O u� Z� 0 O Z � v d w -
Z D �e r z � � ; �
� ' x
�
O N J m
J
.. p
� Z ��
Ir _-
. �_.