HomeMy WebLinkAbout1091A 3538A (5) WORKERS'CO!f.PENSATION DECLl�RATION V � • C/II/�J�� � ��� � �� {�
I herrby aHirm�h�i I have n terrificn�e oi mnsrtnl 1n srtlF ��
;^5���,���«��,�,��.n of W�,k��=��mP��s��,o���S��e��e, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT ��
or o cernf�ed cepY!f�P.�COI(Soc.38. , ob.C.) ,,,,-:j .
C:'%F 17!P.:1
Policy No.����co�,pn�y COUNTY OF LOS ANGELES BUILDING AND SAFETY
� CertYied copy is hcreby furnis�eed.
� Cer�ified co �s tiled wiih ihe FOR APPLICANT TO FILL IN P.UILCING
py' _couniy building inspec• �DDQESS � Q'I'1 Z
tion depar+menl. 9UILDING (
�CDRESS ! �/"�� �p�q�iTy
Da�e�Applicant � � NEnRE51
CE4TIFICATE OF ExEP,!PTION F40M WORKEQS'
CiTr zi� Ceoss si. �
CO.M�ENSATION INSURANCE l SIZE OF �SSESSCR
T4ACT G ,s�v IOT LOT NO. �� �/AP BOpK PAf�E VARCEL
(This iacfion naod not 6�compl�fsd i(fh�psrmil I�For one
h�ndred dollari(5100)or la«.1 Ol\'NCR ' ni0. �" � ��,�`NE Npe ��l 3�
I tcrlify t4at in the performanc�of�6r,work(or which�his
permil is�ssued,I sF.nli nol rtmrloy eny�Prson in ony monner RDORCSS l O w1 SOECIaI
OQV CONDITIONS '
so ns io hecomr.subjrcr to�hr.Werkeri Compensotion Laws. �- D�Slrt!Cl 9AlIS1�Ut CLASS IYPE pRpCESSED P.r
CITY ZIP �� �' COtiS{,
Da'e Applicanl �RCHI7ECT OR TtL. CLASS NO. y
FhG!tiEE4 �! `� YY���y
NOTICE TO AP7LICANT: If, n(�er mnkin�this Cer�i(ica�e ol ������'7 I ' `� ` �v•-••—�
� E.rmplinn, you should become subjecl Io Ihe Wor4ers' � � -�-
Comornsa�ion Movisions of Ihr.lobor Code,you must for�h- �CDof55 /� �f YALUAiIOH.
wiih com�ly w��h s�ch provisions or ihis pr.rmil shnll br. IEL. S I r D�� VALIDATION
c�e.CmCd reve4e�. CONiRACT04,�( No.5qQQ333 �
LICFNSED CONTRACTO45 DECLARATION ���� � '
I I1PlPI)Y(1�IIlT 1I10�I OT Ircensed undcr provis�ons ci Chop•er 9 4O✓pE55 3 N'J, s .
`" 53
(ror�riercing w��h Sr:rlon 7(X10)ci Div�sicn 3 01�f�e B�s�ness CiTv ` CIASS �
a�d Pro�rss�ons Cod�,n d my license is in full forcw�n�1 ef!ect. CESC��Fi�CN G'wCRK '�� �n.� n
�SU Z 7/ FINALX �g�
License Number Lic Clnss� � p�.�} /,U r�� , !�� � 2 1
rr SWIM.V.'kG POOI
^� ��! VJ /� . • a.
Conlr�clnr�'^�t�-� Da�e_,l�L 50 Fl. �f FINAL � • •[f 9.�L� Q
� I am evempt unArr Src. S12E � . 6Y . . . • o •il�C`,�� `L'
B.BP.C.ior ihis rcnson E(ECTRICAL /�� " +� �
/J'LC.� • �0.r— ��ti r I—Qi I
Da�r.: � W
Signoture S�eel R Conduit Banding r �`���6 \ �.
SINGIE FAMILY Condui�s,Conductors,F�uiAmrnt � S � Z
HO".E 01VtiER-RUILCfR IKCLARATION P�U.4MBiNG .
I hereby a!firm thof I om r.emr.�frcm ihe Conrroc!or i Litrnse ► L��)���(,,{«/�' �tl!L �
law for ihe followinp reoson(Secrion 7071.5, Business and P-Tro �
Prof�ss�ons Code): Gas Sys�em
� I,�s own�r of the preprrty,will do the plumbing ond Anti-Syphon .
e1=Urlcol work.I,or my employees with woges os ihr,ir
sole compPnsalinn,or a lic�nsed controcter will do oll MECHANICAL
oihe�work ond itie so-ucturc is nor ime.nded or eHered � ;'j=`R'+{
fer sole($ec��on 7044 88P Code). Swimminq Pool Hea�er v
COVSTRUCTIO.'J LENDING AGENCY �. ' � • ° •
I hereby o�f�rm�hnt Ihrr�is a conshuction Irndin�oqency fo� ppp�ICAN . � ^ � %�J U
ih_ �rformance of ihe wo.4 fo�wh�ch�his TE�� �
^p- permit is iss�nd �PRINT) � No 99 3� ., � � � �/�*"��.�
(Ser.3097,Crv.C.). I 1.1 �7—�7
Lr.nder's Name nDDPE55 � i7 � �
Lr.ndr,r's Address +�-`} /� �.+� �
P.C.Fre S l O 7erm��Fr� �W. � '
I ceri�(y ehn�1 have rncd Ihis applim�ion and s�aie. ih�i ihe
e6ove info.m��ion is conncl.I ogm�lo comply wi�h oll Counly . ��^�l
ordinoncr.s ond S�a�c Inws rr.loting lo building, elechical, Issua�ce�ee � "
�h�nicol ond plumhing consrruclion,nnd hcrr,by nuthorire �^��+'�!1���a^FP" f^ (—y�
repre. n��tives of rhis Coun�y io enier upon ihe abovo- Tr.�nl Fn� J �J V
m. hn ed prop ior' sp�clicn purposes.
GI�-i�� �d/ �77"R�
�� S�q�o��,.r r.r n,ri�rn��n.nqe�i Da�� SEE REVERSE FOR E%PLANATORY LANGUAGE
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