HomeMy WebLinkAbout0993A 2557A (5) ` �RKERS'COMPENSATION DECLARATION � �
in• nrt fhcarta oE tiVorke sr'CompensnNonenzuronce' APPLICATlON FOR C4MBINAT{ON�SWIMMING Pf101 PERMiT �
oqo� .�irieacnpyrherEaf.(Sec.380�,La6.C.} +anzoe � � " �
�p� ��/� CE876(�/86}
volicy No.47�J�1 Company � CO.UNrY QF LOS ANGELES BUILDING AND SAFETY
� Cer�ified mpy is hereby furnished. .
Q FOR APPLICANT TO FILL IN 9WlDING � �
Cerlified copy is filed wiih the county building�n5pec ADDRESS
fion deparimenL 9UIlDING -
¢���.�'� ADDRESS IOCh�TY
Oate St.LS¢.S1.L—Appiica NEAREST
CERSIFfCATE Of EXEMPTION FROM WORKERS' �ITY (�' ZIP CRO55 5T.
COMPENSATION INSURANCE 5¢E OF b asse550u
TRACT ��5 LOT lOT NO. MAP BOQK PAGE PARCEL
(Tbis sx4ion need no1 b�comp�oMd if Ihe p�rmif is fvr ona tEL /�� U ZONE MAV .i/l S 3 3 I
6undred dolkn(5100)or I�as.} OWNER NO.�'7 � �1 NO. V
I cartify�hai m!he pertormance of the work for which ihis /� SPECIAI � � _ �
permit is issued,I sholl noi employ any person in ony manner ADDRESS 0�����1 CONDITIONS
sn os to become subject lo�he Workeri Compensation lows. D{SiRICT� SSATISTiUt C1A55 TYPE DROCESSED 8Y
CITY Z!P CONST.
Dote Appliconl ARCHITECt OR ifL CU55 NO.
NOTICE TO APGLICANL If, after moking rhfs Certificote of ENGWEER NO. ��� �O � �
Exemption, you should become subject to the Workers' qpDRE55 VALUATION
Compensation provfsions of Ihe Labor Code,you must forth- (� VAl10AT10N
with comply w�th wch provisions ar this permil sholl be CONTRACtOR NO. s �J OO�
deemed revoked.
LICENSED CONTRACTORS DECLARATION ���"
ADORESS i' NO.
t hereby offirm ihat 1 am licensed under provisions of Chopter 9 ��� Z
(commenci�g with Section 7000)of Division 3 of the 8usineu ��N ��qu
o�Professions Code,ond my license is in foll force and effect pESCIZIPTION OF WO K
�"�'�9 FINAL L � ::Q�Q�J Fl
Cicense Nomber�.�ll(� Lic.Class� SWIMMING POOI � DATE ��t_l � . . . .C 1 a
Contracto�'�^'�� Date ����7 SPA FINAI _ U
❑ 50.FT. j� BY I � s�G.�J f`, �
I om ezempt under Sec. SIZE t/ �
8.&P.C.for ihis reasan EIECTRICAI s • -;;L�, 'r,-T. O
S—�o.sv.c� �9e,�„� U
�re� Steei 8 Conduit Bonding � G'z,G~`�7 0.
Signature Conduifs,Conductors,EquipmeN ��QbLi �
SINGtE FAMILv � � —
IiOME OWNER-BUILDER OECLARATION p�UMBING � �
I hereby affirm that I om ezempf from the CoNrattOi"s license �
taw for the following reoson(Section 7031.5, Bvsiness and P_froP
Professions Code)� Gas System
� I,as owner of ihe proper�y,will do the plombing and Anti-Syphon
eleclrical work.I,or my employees wilh wages as lheir
sole compensa�ivn,or a licensed contractor will do all MECHANICAI
other work and the structure is noi intended or offered p,.
for sale(SeUion 7044 B8P Code). �Swimming Pool Hea�er V�w � �" "
CQNSTRUCTIONLENDWGAGENCY sp��r ptt�Yh�'1~
�hereby affirm Ihaf fhere is a mnsf�uction lending agency for ����p�T �� ""��""'' � :=2 5 5 r A
the performance of the wark for whkh this perm�t is issued �ppiNi) NO. ' �3�j � �'v�i3� �4¢� j}•.. . • •�
(Sec.3097,Civ.C�. c m /�
Lender's Name ADDRE55 ) /� ( ./ r � ' °C''4'h'��
Lender's Address 4 r l•..���� ���)`���`n'C
P.C.iee S U J Permn Fee � \ ~
I ceriify that I have read�his applicatron and siare�hat ihe I Q� 4�a']
� �bOve informolion Is mrrect.I ogree�o comply wilh pll Coun�y ,O . . i
ordinances and Siote laws relating to building, electrical, issuance Fee
mechaniml and plum6ing mnslruciion,ond hereby authorize �nvestipation Fee Q i�
seMatives of this County to enter upon the a6ove- ToralFee O .�O J ��-"� I
men- ed prop 1or�nspeUion pur�oses. ,
�zy�QO-7� '
S+goorore of Apphwne o�qge�� �aie SEE REVERSE FOR EXPLANATORY LANGUAGE
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