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4 WORKERS'COMPENSATION.DECLARATI4N - - - . .... .. _ .-_. .. -_. -rt` - � - . ��...'
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insure��rao;cerfif��e7•e4�f�lNorke�srtEompensatioolnsumncef" - - � _-.
AP���A�IQN_FQR C4l�81NkTtOM SWlMAI[!NG FOOL PERMIT�
or a cerfifeed capy ihereaf(Sec.3800,-Lab..C,) ..- � 76a2oB �--�. -' .- .. ..
� I , ���ry� �J �� �u N� GESl6 S3/841
PolicV�N��t�J�,y�����Y v�t4 .. Ct3UAiTY OF�OS ANS'rElES -_ ..__BUlEOU+IG A[+IQ SAf€TY ---__._--,
� Certif ed copy is here6y furnished � �- `-� _� - --_ . -- .. . .
..Certified c 4s�f�fed w�ih�ihe coun buiW' +n�. -�QR�1P��[��ftdl�Q ft�L-�1 '.-� - BWLDlNG ..-/�-� �- � • .. ..- . -
opY !Y_. � sPec' ._.. _ _,_ __- ADDRE55 � V�J -� F�C!�,}..
�.lion department:� . ... . ., �.-: BUlLDING � . - . .. .�
aooRcss 4 b .0 (ri .s�•[ iacaurr [�I --1 K•
� Da�e�/uiPi'rco � . G .
� CITY .ZlP �AREST
�CERFtftCRTEOF"EXEMPiIONFROMWORF�RY� -�- - - 7 CROSSst'�.
- � ��-- -CQMPENSATIOPI-INSURAMCE y�+ SrZEOF qS5�55pR - - �
7F1is NC/ip�1 1fi�d Iro}jy��q 7RACf ia�� � LO7 FOi NO. MAP BOOK PAGE GARCEL
[ plef�d H}[�parmff is Eoi on� rA
ha�rad ddbn(fTW�yer Iess.J- -- . . . .. own�R!`• i C H�.ti �!. _� usf zor� � .. ,�3„3� ..
1 cenity ffiat in the perfwmance-of the work for wFith ihh � - SPEGAt -
permit is issued,i shafl nof employ any person in a�y mpnner ADDRE55 - - ��� CONDI7ION5 �
-�-so,as to become su6jecf to fhe Wo�keri Compensafion Lowa �- �` � � DISTRiR STRSfSi1CM1l CLA55- - 1YPE PROCESSED BY -
C17Y /— DP ( � �� ����. � CONST. .
�Date Applicam ... ARCHfiECf OR -� 7EL. 7/ ' !
NOTICE TO AVPtICANT� ff, after moking ehis Cert�fimre of E���R '4� � � �
Exemptian, you Should become wbjecf to the Workers' - VALUATION . �
Compensafion provisians of the Labor Cade,you�must.forth- R��� �� (� ;
with rompty with such provisions or this permit shall be �t�A� � ThEpL. ���� s i7 YA1WASi0# �
deemed revoked. � . . V I
- FICENSED COMRACTORS DECLARATION- � E�� .
Iherebyaffirmtknt.t.amlicensedureder�prevrsiomafthapter9 ADURE55 �O NO. - � . .. , .
. (commencing wlth$ecfian 7060)of Division 3 of the 8usiness - �� ��' �� '� ' S � � . . � - � -
�
ond Prafessions Code,ard my�license is en fuii fwce and affect ��n .
.. �ffJ.�{L"3G -_-� WORK F�iAt � .
liceme Number������' C�ass ��1��� . QATE ► . � !�il 5,9 E{ �:
sw�nnnwc roar
Con1.o��oC��NTtl/ZS+ x!f��� ����f �'" � F�Nwi #•• a •�7 g
o �.� s�
E am ezemp/under$eC. - 5�� F • •�E.�'J �`
- 8.8P.C.for this reoson �� .. ..... . . _.-. ti , � a �
. ELECFRlCAI - a.o e..G c.'�t,
be�e: � W
-9 Steel 8 Condui�Bundir�g �- ..�y� Q� (i Q G�-�-� d
� Si naNre � �� � Co�uits,Conducton.Equipment � z
- -SI FAM{LY - �J .
HOME OW - 7LDER AECtARATIpN PLUMBING .. o(,5��y � . � -
i hereby offitm thot 1 .exempl from Ihe Contmctm's License �9 ' , . � -��
Law fo.the following reason(Sechon 70.3t.5,�Bosiness and P.T�aP r-�t n�� ► �
Professions Code): - . Gos 5 stem � � . ..�.. - . - . �
�c
� I,os owner of Ihe property,wiFl do the piumbing and Artfi-Syphon �1 �J.v A
elechim[work.1,or my empbyees witb wages as their . . � - T+ •�• �c3
sole compensotion,or a lice sed ca t actw wilt do all MECHANICAL �
other work and the strudure Es not mtended or offered ... .. . _ � /� � � � ' � t Q��,5(�'
for wte(Setfion 7044 B&P CoBe)- � -�- - Swimming Pool Heater + �
CONSTRUCTtON LEND(NG AGENtY �- �i �����0�
I hereby aHirm thei fhere is a construUion lending ogenq fa pPP41�T �, -�J � . �9'��.,_��
the pedormance of rhe work for which this permir ia issued (PR�M) Y 'C NQ- - s�5' .� �
�Sec 3097,Civ.C.). p . . . .
lender's Name � A��REu 'C y �
lender'S Address � ��-ry . pQ � .
P.G Fee f �74p ��� Permii Fee �I - �
�cerfify Shos 1 hove read this appficoiion qnd stote thot fhe . .
above irrfwnwtion is correcF.1 agrteYo comply wiitr oll CovntY . -f('J. ,j'v � �
ardinonces�ond Sfa�e ws reMating ta building, etectrimi, �uuanc�Fee �
mechanical and plu ing construction,and bereby authorize �^�������on Fee . �n O r�
represent "es o �his C enter upon the o6ovB- - Towl Fee V J
_ menti o ry fo � ' n purpozes. �
_ --�=��6 ��
u of ty,plKom«age�r pote SEE REYfRSE FOR EXiLANATORY IANGLIAGE � �
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