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HomeMy WebLinkAbout1016A 1394A WORKERS`COMPENSATION DECLARATIDN � � ���I�� � insurebor�o ce.�cate of Workers~Compens�'on Insorance'f APPLtCAT10N�f4R CQMBINATION SWtNtMING� PQOt PERMIT � or a mrti�led copy therevf(Sec.3800;La6.C.) � �snzoa -��-------- ��� - - � � - � �I���/[�� GE8�6�3/842 �P-o�7licy No.i��u+-e--�-u-ompany . GOUNTY OF LOS QNGELES .BUILDING AND SAFETY . � Certi£ied copy is hereby furrtished. � . � - , FOR APPIICANT TO FILL IN BUILDING Certified.mpy is filed with the counrr��xtvyy building inspec- ADDRESS� � , t//i��on�epartmeM. x�1�'\G1\\�� BUVfDING �f ��PP �-` �'�'�'� AooRE55�!O locat�iv Date A licont K NEnREST -�- CERTIFtCA7f OF EXEMPTION FROM WORKERS � ��TM � �P - �Q��" � - COMP€NSAAON INSURANCE (7� $�ZE OF ! '455ESSOR . TRACT �(] [07 WT t�. 1 hVtP 900K VAGE PAREEL (This a.cNnn n.«I wot 6e comptNod R tb�pwmit is for one � �Et. u5E zor� nviP + l, hundrad dotlers(ikQQ}er Isss.} �� . OWMER N6. Nb. `� '�`� 1 ceraify that in fhe performonce of the work tw which this - ��� . permit is issued,I shall nol employ any person irt any monner noDRE55 CON�RiONS so as fo-6emme subjed to the Workers'Compenwtion LawS. DISTRICf STqTISTI�AL Clq55 , TYPE PRQCE D BY GTY ZIP Date Applicant . ARCHITEGf - — � TEt. �.((�.f�� ���.2 N4FICE TO APPUCANT: If, ofter making this Certificate of E�'��� � `�`�' "�`� ,� � '^"-'� � Exemption, you sho�ld become suhieu m the Wo�kera' � y�pqnpg " ' � - Compcnaotion pwvisions of the Labor Code,you-must forth- A�Eu ���.� --`� YALIDASlQN ith comply with such provisions or this permit.sholl be �� � � cj Q ��� ; #�3 deemed revoked. CONTRAC70 -NO. LICENSED CONTRAC70R5 DECL4RAFION ��� ���. fT �f n � q i Q - �i C���6 a �1 hereby offam fhot t om iicensed Lnder provisions of Chapter 4 � Y �d, f - . 1 (commenting witFi Setlion 7006)of Divislon 3 ot the Business ��n, �� .�- , t!a e +w�� : orui Rofess+ans Code,ond my Iicense is in fult force and effect ��R pF WOtiK - �� - - o - � Licanse Number Lic:CIo55St�� SWIMMING POQL � � hE`Z Si� � ( + •7 u 8�� j-;'~������ �p t a .7 4.fi 4� a -cono-oc�b�i � y Z-S'�a SPA � . _.. . ❑. . S4EiT. _.B�` Q�2 Jr Pi 7 � �f am exempt under Sec. D- � - B.B.P.C.for ihis reason �ta: .. . .. ElECTRIEAL � � - . ����� � � 9 � Steel 6 Conduit Bonding � �- (��,n_ �(�s$'b� d Si rwture - ' Conduits,Condutlors,€quipment Y��—N`n d` � z ' SWGLE FAM7LY � _ HOME OWNER-BUIIDER DECLARATlON �PLUMBiNG � � I hereby affirm thof 1 om exempf from Yhe Conhnttw's License � - -lpw for the followF�g reason(SetfiOn 7031.5,8usiness and P_T�aP � � � - Profession:Code): � - Gos System . (� � ,�� � � ,�(� - � � t,as owner of the prope�ty,will do the plumbing ond AntiSyphon r (�jp.J���t-�`��'�' electrim!work.1,or mp empioyees wiTh woges os their - . � ����� .. . - sate mmpensotion,or a lirensed cvMroctor witl do oll MECHANfCAI � / other work and the srrocWre is noi intended or offered / {or saie Section 7044 B8P Code. . " . . . C'7'1 . � ( ) Swimming Pool Heater- LK� - . . CONSTRUCTION LENDWG AGENCY �� 3 q�4 A I hereby offirm that there is a construction lending agency for AP7LKANF 7��. .. � �� � � . .3 the performonce of ihe work for which�his permi�is issoed _ . �pq�NT� pp. _ � � � (Sec.3097,Civ.C.). . Lender's Name . - ' •����a AODRE55 ,` ((�� _ _ _ .ti27550� . lender's Address ���(� � .('�'� . . � .G��&„8 7 V.C.f�S 1 S �mif fee \..J._� ... �cerfify ihat I hove read Ihis opptimtion ond stale Ihat the . . - above inEormation is mrred.I og�ee to comply with ol!COunfy -- . � ord'rnances and Srate laws relating to bailding, eledricol, - IasuonceFee- - � - mectwnica!and plumbing construc�ion,and hereby authorize Invesrigo�ion Fee . . - represe tatives of this County lo enter upon the above- � Towl Fee . menlione pPerty for inzpecfion porposes. � � - - -� �_� �-�Z�~� ( �graWre df AppNcant or Age.+t Dote -- SEE REVERSE FOR EXPLANATORY LANGUAGE N O L � G v 0 O^ � y m O � �'.O�+m- D � _ �s� �'o c o o N' t� v v� o o E� � � o �4 V a.: � �, N � .:N Sd � U� NV „� .L �' y���L � y� . � � . . 61 r' YI O, a�O N �r J 7 E N �, — O `J-.V r..ol 0 y w :Q', m= � °a " ° c d ° m N °t °v E m` ��3 m O 'o� z��oN° c°' �N � ° vd � 3or'-oN ; � o ° °c_ Z 0 0 �,�o m o'��O v ° N '- �'= °+ + � 3� m N -mo-o �'° o a °N cc r c� � o,� °' � o Q "m c � -°u o Q n.�"�o m'� �� ,�'.N° �-o $' m � � o J � v > E a £' � a >' u o �'> Ea� ,y ;n a,w u ,n c� v $V� o � cooEdoo � ;s E=-o � Q'^ Qoy �o aodo.� oa W .'Q .°'c�r;'° n.�d d�5 :� '_ � �- � °r o o a y ° 3 v '•.`s° n`. o� o m c � Z ,�,,.�. %o:.-t E , p�a.m m T E o � o o ci m�tl p�-o � °'o �o v � m � � ' ,� 0,,6" • r. - ° m+� Q a� o.° o o ;L a-� L s, v o m o ° °; E 4*+- m'c �' o E c a a o�� � c v v o ; o c o + o o� � n.�=+ m E pa d d N c si•- rn �n v� x '� `a m a' ° .. 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