HomeMy WebLinkAbout1546A 1904A (9) IWORKERS'COMPF�SATION CECLnRATION
� 1 herrby nffirm,F,�, ��a�P n ceniiicate o��o�,P���o sr.lf APPLICATION FOR COMBINATION SWIMMING POOL PERMIT �
Iinsore,or'(�ce���hta�e of Workers'Compensa��on Insurante,
or a cr.rtilied cepy thereol(Sec.36Q0.Lab.C.) -Enac�
CEe76�7/fl�1
voGcy N U����mpa�v ����r�/� , COUNTY OF LOS ANGELES BUtLDING AND SAFETY
� Crtified copy h here6y(um�shed. � ' '
FOR APPUCANT TO FILL IN eu•iowc
errified copy is filed wiih ihe counry building inspec• AODRE55
t o�depar�menl. BU�L�iNG �- �l� (�
/� .4CCRE55 � � _.1. .i.-I'-Y� V LOCALITY
Da�e t/r �l Appli[ant f7-UC '�l%'1r'ZZ�.'� D, n _ NEAREST ��
r'i tiv d;;/ caoss sr. O � �.
�CERTIFICATE OF EXEMPTION FROM W04KER5' ��TM � �� 511£a " ASSESSOR
COMPENSATION INSURANCE TRACT�i��S lOT lOT hO. � MAP BOOK - PAGF VARCEI
(Thit s�cllen n��d nof b�complN�d 11}h�p�Imil i�For on• �. � j N � TEI.�^ USE 20NE NAP �
Aundrad dollon(5100)er I�s�.) ONN f11 V^�-�-=1v—+-�c-�-la NO �� �7i7 NO.
I ceriify tha�in�he perfe�monce of�he work For which ihfs "� SaeCinl � �
permit is�ssued,I sholl no�employ ony person in ony monner PDDRESS �, � � CO�IDiTiONS
so as lo become sublecl to the Workeri Compensorion laws. � ^ /� D!SfR�CT STAlIS7�CAl CLA55 fvPE PilpCE D BY
' c�n �--�' f Z�P �� ClASS NO.� GO�vST.
� pate Applico�� ARCNIiECT OR � TEL.
I NOTICE TO APPLICANT: IF, o(�er moking Ihis CPrtliim�P of ENGL'JEER �, y4� !� � NO.�i i�� '�Y
� E.r.mp�ion, you should bncomn subjed �o the Worke�s' l ' ��� , VAWAT�ON
Compensonon provlsions oi the Lobor Code,you most fo�+h- ADDRE55 1 (�i i� • . +.L�_ s��Q VALIDATION
wiih comply wiih such provisions or rhis parmi�sholl be �«'�3 � �
decmedrevoked. CONiRACT04�: f `_--_ 1-s / ,'1�, �NO.'.y�-:"' � _ ,
IICENSED CONTRACTORS DECLARATION /i ���' /
nDDR:55� ,Q � �!�: h0.� ��� S
I hcreby offirm ihal I am licensed under provitiont of Chopter 9 � ���. _
(commenc�ng w�+h 5^cnon 70(101 ef Divrs�en�oi the Bus�ness CiTV , C�A55 � " _'� �`�'.�`1'i
nnd Vro(ezsinns Code,ond my Gcrnx is in fuil iorce nnd eHetf. �K��cT�Ov wCae y _
-7' /-C" � FINA ,
liCenSe Numbe.r�`•���� lia Clasl�� SK'INM:NG GOOL �7 O�TE / v • • c C(1
'.Z.L.�� /"� Y�� � I'„ /7/I%.i'"'+ SPA � L�1� FINAL � � �n'„ i }
Controc�a�, \ 'Daie SCj f!. ��--y1ri / eY _ O�
� I nm expmpl onder Sec ! '� SIZE JIJ��' �•. ' `� .. . "`- O
U
Q�.� J- �.. �
R.BP.C.for this rr�son ELECTRICAL �
Da�e: �
S�e.el R Co�dui�ea�ding V
Si��o�ure Conduits,Conductors,Equipmenl . W
a
SINGIE FAMIIY �
HO"d.E OVlNER-BUILDER DECIARAT10N PLUMBING ► Z
I hcrr,by oSfirm�'�ot 1 nm ewempt from Ihe Comrotlor's License � � .
Law for the(ollowin3 reason�Sec�ion 7031.5, Business and p.Trop
�.o(easiors God^): � Gas Sys!em �
� 1,as owner o(�he praperly,will do�he plum6ing ond Anti•Syphon .
elechicol work.I,or my employaes with woges os�heir
sole rompensai�on,or o I�tensed connactor will do oll MECHANKAL
o�Fer wcrk and�ho strucWre is not in�ended ar oFfered
icr sale(Section 7044 BRP Code�. Swimming Pool Henter � ,:� Q(i[.i'�
CONSTRUCTION tENDING AGENCY ' _
I he�=6y afi�.m ihat ihere is a constr�crion lendin9 agency tor APPIICANT � �Fi. �:e • • o .�j
the performvnce ot�he wo�k for which ih�s pc�m�t is iesued �pp�Nl) ��1� 1� ? � �p, . ,
(Sec.3097.C�v.C.). ) o tl � • � JO���
lende�'s Name AODCE55 Qr ^�-ti n_Ir LL ,� • n � ,, .:n`
lend��s Address p.C.F�e S O Fermu Fce I `'T�Qv C�.r F-"•`;
I c^rlify�hol I ho�e rcad ihis applimrfon ond sia�e Ihat Ihe try rt
obovr,iniormolion is correcl I egrer�o comply wiih ofl Coonty � Issuance Fee lv�V
ordinonces nnd Sia!o laws relo!ing to buildin�, electrical, , .
mec��anical and PI 'nq cons}�uttion,ond fiere6y aulhorizn Im�s���o��on�rn .0 O '
represen+a�ives th' unly to nnler upon the a6ove- Toinlfee J _
me��pm erty�r injpettion pur�eses.
// l C ��
/ / _-3,.
/s+g�oru.e'ncni�ca� �r nq•oi � �aid - SEE REVERSE FOR E%PIANATORY IANGUAGE ,
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