HomeMy WebLinkAbout1052A 1053A (7) 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
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