HomeMy Public PortalAbout11026 GREEN TREE LN_Swimming Pool__ WORKERS' COMPENSATION DECLARATION
' hereby 6fftmthat I hav: a certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificatc.of W. kers' Compensation Insurance,
or a certified.copy tyereof (Set. 3800, Lab. C.) 76A2oB
CE876(3/84)
POI y�* �7� Company �I- �u/� n � COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING ®.2,to ��f ��� I
Certified copy is filed with the county building inspec- ADDRESS L�
ti n department. c BUILDING ��-{-�-�v ( �p,� / ,,
ADDRESS n �Y �� 1 l�L l L/lt`2_ LOCALITY 1/I r1 lX
Date 1 Applicant r NEAREST
CITY e31 ZIP [ `S CROSS ST. t/r
CERTIFICATE OF EXEM ON FROM WORKERS' SIZE OF ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one t J TEL. USE ZONE MAP
hundred dollars ($100)or less.) OWNER L-1�i l�Z N0. �5`J i4� NO.
I certify that in the performance of the work for which this 1� �� 1 Y ` SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 1 CONDITIONS
so as to become subject to the Workers'Compensation Laws. pp 11 )) , / DISTRICT STATISTICAL CLASS TYPE PROCESSED BY,
CITY�ehll�ILL (�( � ZIP 1�r�0 COWT. /]
Date Applicant ARCHITECT ti / CC� Jp� CLASS N ' // ,//
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ( 32) ��D�/D U�
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS -l�W I t ) (�U�Y1/Vti �L�
TEL.
with comply with such provisions or this permit shall be ry l i VALIDATION
_
deemed revoked. CONTRACTOR l�� DD/S NO.` D Z7 ✓ vIILPP°v
[� ^� i!
LICENSED CONTRACTORS DECLARATION ADDRESS /` 1�/ :S� ( /?' O LIC. a! /CJI �C
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY �j1TVT ► `�� CLASS -�
and Professions Code,and my license is in full force and affect. DESCRIPTION OF WORK
FINAL f
License Number _Lic. Class V SWIMMING POOL f//�„ -, � DATE ` / ► ,, a
Contract , �+ atSPA FIN U
I am exempt unde Sec. SIZE cJ
B.&P.C. for this reason O
ELECTRICAL
Date: W
Steel & Conduit Bonding
Signature Conduits, Conductors, Equipment c 8 7 7 8 A Z
SINGLE FAMILY -�
HOME OWNER-BUILDER DECLARATION PLUMBING ® # a o o 2
I hereby affirm that I am exempt from the Contractor's License o 95.9 5
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon ° a a 9 S 9 5 c=i
electrical work. I, or my employees with wages as their 0 1. 1 G•,: