HomeMy WebLinkAbout1711A 1712A (10) WORKERS'COMPEN:ATION OECLARATION �
I hereb affirm that 1 have a certifim�e of consent to self �
insure,or a cenif,cate of Workers'Compensation��S��e��e, APPlICATION fOR COMBINATION SWtMMING POOL PERMIT '
or a cer�ified copy thereof(Sec.3800 6 C.) ;sn2aB �
1�� � �E87fi�3i847
Policy No��Compan 7�. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is hareby furnished.
fOR APPIICANT TO FILL IN BUtLDING i.
� Certified copy is filed with the county building inspec- A�ORE55
tion dapartment BUILDING qr o -
Date1��APPIicaN �,��,� ADDRE55 p(J � �./C./ tOCALITV
NEAREST
CERTtFICAiE-OF EXEMPTION FROM WORKERS' CITY ZIP CROSS ST. �
COMPENSA710N INSURANCE {�' J S�ZE OF n55E550R
'TRACT �"��/ LOT LOT NO. MAP BOOK PAGE PARCEL
(This a�efion wa�d nof M comple/ed if fhe permit fa for one � TEL � USE ON MAP Q�`'j 3-r
hundrad dolkn(5100)or los�.) � ''OwNER NO. ��� NO.
I certify thot in ihe performance of the work for wh�ch�h�s �p� �.d SPECIAL
permit is iss�ed,1 sholl no�employ any parson in ony monner a A�DRE55 �� CONDITIONS
so as to becoma su6ject to the Workers'Compensation Laws. �ISTRICT SiAiI571CA1 CtA55 7YPE PROCESSE�Bv
!CITY 21P CONST.
Dote Appli<ant ARCHIffCT Q 7E� /p' � ClASS NO. �
NOTICE TO APPLICANT: If, after-making this Certificale of �ENGINEE � NO.bJ��� � �
Eaemptian, yo� should become su6jecl to the Workers' ;A�DRE55 ' �ai�L`� VAlUAl10N
Compensotion pwvisions of the lobar Code,you musl forth- , / /� VALIDATION
with comply witb such provisioas or this permit shall be f��TRACT TE"`�� (' S /�oOO�'-^ �
deemed revoked. r'+�i7 .
UCENSED CONTRACTpRS DECLARATION - «�'
ADDRE NO.
I hereby utfirm�bo�t am licensed under provisions of Chapter 9 ��� ��� S
(commencing with Section 7000)of Div�sion 3 of tbe Business ,��Ty ��� Li� �
ond P.ofessions Code,and my license is in f�ll force and effect. ��R�vnON OF WORK
F4NAl �
License Nombe�Si��Z� ���.cio:5 � � swunneir�vooi ,.��-�7 DATE z 1 7 1,1 A p�.�
Conhoct Do�e y� SPA r' ' FINAL . • o
❑ SQ.FT.�7 O !Y �.• •2� U
I am exempt uoder Sec. SIZE �
f • o6�197 O °
B.BP.C.tor th"rs reoson F-
EIECTR�CAI Q i
Date: � ��'� • e n b:.`: i u W ?
Si nvture Steel 8 Conduit Bonding �� 0- �
9 Canduits,Conductors,Equipment �����-�J N
SINGLE FAMILY ' Z
HOME OWNER-BUtIDER nECIARATIQN PLUMBING
i hareby affi.m tha�I am exempt from rhe Contractar's License � ' -. , . �
Low for the fol�owing reason(Secfion 7031.5, Business ond p-Trap
Professions Code): � 1
Gas Sys�em
� I,as owner of rhe properry,wil�do rhe plum6ing ond Anti-Syphon =`I 7 L�A �
electrical work.I,or my employees with wages as their
sole compensa�ion,or a licensed controcror will do oll MECHANICAL {`,• • • . •j
olher work ond 1ha structure is not intended or offerad y��� .
for sale(Section 7044 B8P Cade). Swimming Pool Hea�er L/J— � 0 2��,S Q
CONSTRUCTION LENDING AGENCY , � -
I hereby affirm ihat there is a construction fending agency for qpp��GyNi TE�. � '��r��J�'u
�he performance of ihe work for which this permit is issued (ppiNT) NO.
(se�.��,c�,,.c.�. � G 7,2 6—8 5
Lender's Name A�DRE55 I
lander's Address �J (�' p� �
P.CFeef ��� PermitFee ✓�IVr
I certify tho�I have read�his opplicarion and state�hat the �
above information is correcr.1 agree to comply with all County
ordina�ces and Stafe laws relating to building, electrical, Issuanre Fee U���
mechonical and plumbing construction,ond hereby authorize ���estigorion Fee r
iepresentofives of lhis Couny lo enter upon the above- Toml Fee � �.�J � �
memioned p�operty for inspeUion purposes. , �
,�N.r� �-� - I
S�9nawre o�AppLmM or Agant Da�e SEE REYERSE FOR EXPtANAiORY LANGWGE
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