HomeMy WebLinkAbout1546A 1904A IWORKERS'COMPF�SATION CECLnRATION
� 1 hereby nffirm,F,�, ��a�P���,���;«�e o+�o�,P���o sr.lf APPLICATION FOR COMBINATION SWIMMING POOL PERMIT �
Iinsore,or'(�ce���hta�e of Workers'Compensa�ion Insurante,
or a cr.rti(ied cepy thereol(Sec.36Q0.Lab.C.) -Enac�
CEC76�7/A�1
voGcy N U����mpa�v �`���r�/� , COUNTY OF LOS ANGELES BUtIDING AND SAFETY
� Crtified copy is hereby tum�shed. � ' '
FOR APPUCANT TO FILL IN eu•ioin+c
errified copy is filed wiih ihe county building inspec• AODRE55
t�o�depar�menl. BURDiNG �- �l� �
r .4CCRE55 � ,� J.:1� .rI'—Y� LOCAIITY
Da�e t/T cl Applicont P7�C 'rl�i'1/�Z�.� _� NEAREST
D._ n � tiv d;;/ caoss sr. O �� �.��
�CERTIFICATE OF EXEMPTION FROM WO4KER5' ��TM � �� 511f a " ASSESSOR
COMPENSATION INSURANCE TRACT���S lOT lOT hO. � MAP BOOK � PAGF VARCEI
(Thit s�dlen nod nef b�complN�d 11}h�p��mil i�For on• _r. � 1 r � TFI.�^ USE 20NE NAP �
hundrad dollon(5100)er I�s�.) ONN f11 V^�—�-=1.��'+-�c-�-la NO �� �7i7 NO.
I cerGfy tha�in�he perfrnmonce of�he work For which Ihis �� SPECIAI � �
permit is�ssued,I sholl no�employ ony person in ony monner PDDRESS �. � � CO�IDiTiONS
so os lo become sublecl to the Workeri Compensorion laws. � ^ /) D!SfRiQ STAlIS7�Ul CLA55 fvPE PilpCE D BY
' cin �--�' f Z�P I� CLASS NO.� GO�vST.
� pp�� Applico�� ARCHIiECT OR TEL �
I NOTICE TO APPLICANT: IF, of�er moking Ihis Cnrtllicaln of ENG'NEER �, � !! ` NO.�i'l� '�Y
� E.r.mp�ion, you should bncomn subjeU �o the Worke�s' l , ��� , VALUAT�ON
Compemonon p�ovisions oi ihe Lobor Code,you most fo�+h- ADDRE55 1 (�i i� • . =.C�_ S�^Q YALIDATION
wilh com�ly wi�h such provisions or this �lr.rmil sholl be ��TRnCTO4Y: f � � + ,l�, 1 NO.�/7�J—:�� � � O ,
decmed revoked. - � '
IICENSED CONTRACTORS DECLARATION /i ���' /
nDDR:55� ,Q � �!�_ h0.� ��� S
I hcre6y off�rm ihd I am licensad under provisions of Choprer 9 � �i�, _
(commenUng w�+h S^cnon 70(101 ef Divrs�on�oi the Bus�ness CiTV , C�A55 � " i_� r�'.J 1'i
nnd Vro(ezsions Code,ond my I�crnx is in fuil iorce nnd eHetf. �X�;ci�ON wCar y _
-7 FINA
Z\!?��,T �— " .r • • c C:l
l�Ce�Se NumbPr � l�[.Clasl�� SK'INM:NG VOOL O�TE � ► ,
�I/ / /-� . � � � • .p '.
Controctor�^t�� I , L��'Daie I=1}/I%�i'"'+ SPA FINAL •. ." , �-
�
� sci ct. �S-�� er - O
� I nm expmpl u�der Sec. f SiZE C'�., J— ,'l �
8.8P.C.(or this rr�son ELECTRICAL �
�a�e: F"
S�e.el R Co�dui�ea�ding V
Si��o�ure Conduits,Conductors,Equipmenl . W
n.
SINGIE FAMIIY �
HO"d.E OVlNER-BUIIDER DECIARAT10N PLUMBING ► Z
f hcrr,by oSfirm��ot 1 nm e.empt from Ihe Comrotlor's ticense - � .
Law for the(ollowin3 renson�Sec�ion 7031.5, Busi�ess and p.Trop
P.o(easiors�od^): � Gas Sys!em �
� 1,as owner o(�he praperly,will do�he plum6ing ond Anti•Syphon .
electricol work.I,or my employaet with woges os iheir
sole compensaiion,or o I�tensed contractor will do oll MECHANICAL
o�Fer wcrk and ihe sh�dure is not in�ended or offered
icr sale(Section 7044 BRP Code�. Swimminq Pool Henter � ,:� Q(i[,i'�
CONSTRUCTION IENDING AGENCY � _
I he�=6y afi�.m ihat ihere is a construcrion lendin9 agency tor APRICANT � �Fi. �:a • • o .�j
the performonce ot�he wo�k for wh�cb ih�s pc�m�t is issued �pR�M � � n0. � ►
�se�.309�.c�.c.>. � ���r �J ; , ,� � • 1 5 n�v
lrnder's Name ADDGE55 Ql ^n-ti n_1 r Lj_, ,� . ., � �, ,:��`
lend^r's Address P.C.F.e S O Fermu Fce I �7.�'.v`�' ��,r F—"•i'
I c^riify thol I hove read�his a�plicorion ond sia�e Ihat Ihe /� rt
obovr,inlormollon is conecl 1 egrer�o comply wiih ofl Coonty � Issuance Fee �v�V
ordinonces nnd Sio!o laws relo!ing to buildin�, electrical, . .
mec��anical and PI 'nq cnns��uction,ond fiere6y aulhoriin. Im�s��go��on�en �O '
represenfa�ives th' unly to nnler upon the a6ove- Toinlfee _
me��pre ert�//r injpettion purpcses.
// l C �� _�
/ / _-3,.
/s+g�aru.e'1�cni�ca� �r nq•m / oaid -� SEE REVERSE FOR E%PIANATORY IANGUAGE ,
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