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HomeMy WebLinkAbout1048A 1111A WORKERS'COMPENSATION DECLARATION ' I hereby affirm that I have o certificot�e of consent lo self APPIICATION �QR COMBINATION SWIMMING POOL PERMIT � insure,or a certificate of Workers'Com ensation Insurance, or�a Fer�afied c�oLpy thereof(Sec.3800,Lab.C.} y. 76A20B W�O�� i a.�j� �Al..w..�w• CE-B75(l I/61). . . Poticy No. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished. �� �_ O FOR APPtICANT TO FILL IN BWIDMG a U O S Q' Certified copy is filed wifh the county 6uilding inspeo- A��RE55 tion department. � BUILDING ao�Ress 2 o y�S /1 w�-r,rr ��H�ff �ocauTv (Q iYL Date Applicant NEAREST l CERTIFICATE OF EXEMPTION FROM WORKERS' C�iv �� /'�Q. 21P CRO55 5T. t.z� COMPENSATION INSURANCE TRA� s��f� SIZE OF ASSESSOR l0T LOT NO. �J MAP BOpK PA PARCEL (ihi�socfion nwd not ba wmplafad if tha pormif is for ona hi. U pNE N„qp 6��a,�a a��b..�s�oo�o,�....> OWNER �f.3,�rs�� No. �. �/� - 3 t certify ihai in�he perfwmance of rhe work for which ihis y p [�U SPECIAL ' p@rmit is issued,I sholl not employ any person in any manner AD�RESS �`�.S �°"����"r /���'� �" COMDiilONS so as to become subjeci to ihe Workers'Compensa�ion Laws. �ISTRICf STATISTICAt QA55 TYPE PROCFSSED BY CITY �`BI��- ZIP CONST. ��'///111 //� Date Applicanf ARCHITECT OR � TEL ��� %� C��. �' /)�! ,� NOTICE TO APPLICANT: If, after making ihis Certificote of ENGINEER �a NO. o � r 4l Exemption, you should 6ecome subject �o the Workers' VAIUATION � Campensafion provisions ot the CpbOr Code,you�musi farth- A�DRESS / / `` VALIDATION with comply with such provisions or �his perm"rt shal! be ��TRACTOR �yL"t� �`�t' TNO 4�7 spy s `=� �U V deemed revoked. LICENSEO CONFRARORS DECLARATION �( p /� � A����' p 1 hareby affirm Ihot I am ticensed�nder provisions of Chapter 9 '°'�ORE55 7��tl /c���f��-rr�0. �a s��L f (tommencing with Section 7000)of Division 3 of the Business �p ttC. aTv cvss C_�S 3 � and Profeuions Code,and my license is in full force and effect. d Oe� �^ OESCRIPfION OF WORK F{NAL � � O LicenseNumber �+✓�A LicClass C`� SWIMMWGPOOL ppTE ,{�:.,��^�' u Confrocfor ���� �'� Dats - �A � FINAL � - so.FT. ev � I om exempt under Sec. SIZE ��� �,� O�8 A y B.&P.C.for ihis reason ELECTRICAL � -#���� �2,� z Date: Steel 8 Conduit Bonding . . � • •6�9 7 � Sigrwture Condui�s,ConduUors,Equipment SINGIE fAMILY � ' • • �6,Z„9 7� HOME OWNER-BUILDER�ECIARATION PLUMBING � �� � I hereby affirm that I am exempt from the Controctw's license � , -- � � ' 0�•� b�'8.� � Law for ihe following reason(Section 7031.5, Business and p-Trap Professions Code): � � � Gas System � � I,as owner of the properry,will do ihe plumbing and Anti-Syphon elecNical work.I,or my employees with woges as their sole compensation,or o licensed contraUor w"ill do all MECHANICAL . other work and the structure is�ot in�ended vr offered � z 1 1 1,1 A for sale(Section 7044 88P Code). Swimming Pool Healer � �� CONSiRUCTION LENDING AGENCY 3 3 3 O� ,�T�+'- #• • �3 1 hereby affirm�hat there is a construc�ion lending agency for A���NT TE� � •2 2 5,j Q I the performante of the work for which this permit is issued PRIM NO. �se�.3oa�,c��.c.�. � � � ...�2`a 5 0= U � tender's Nome A�DRESS 0 1,�0—8 4 ' Lender's Address q I P.C.Fee E '�, [ Permii Fee ! � �u I certify ihot i have read this applica�ion ond state�hat�he � � obove informalion is mrrecL I agree ro comply with all County � �(�. 5(� ordinances and Srare laws relating to building, electrical, � Issuance Fee methan' I and plombing tonstrudion,and hereby oulhorize Investigotion Fee , �U repre nl tives of this ounty �o enter upon the above- Toml Fee o1 S men on d p r for pection purposes. � /—l6 g� ' n ure of Applimnt or Agem � Date SEE REVERSE FOR @%PIANATORY LANGUAGF . � � � ,� 4i 0 Cl � V U �� � « � � I � �?V N d �L � �" �in O�� � . �� 4 N O .O �_ C�` G: O ��.- I 'aM:c - ` o 3o� .yQ� �3 ao ��_ � o L o .o� a` � o � �a3a � �o � mo c �n � u�L cmo �. 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