HomeMy WebLinkAbout1016A 1394A (5) 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
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