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HomeMy WebLinkAbout1341A 1342A 5V0?XERS'CO'.".FENSATION DECLARATION �I��� � - ' � � � I hr.rcby a(firm :hot I hovr o cert�(�rn�^of�0�5���ro sclf APPLICATION FOR COMBINATION SWIMMING p00L PERMIT � insu�e,ar a�ertific��r.of Wnrk�rs'Comprns�tion Insurancr., or o mriified cepy�he.eof(Set.3fi00,Lnb.G) �qn?^3 �=?'fi 17'P�I Pol�cy No. Company COUNTY OF LOS ANGELES BUILOING AND SAFETY � Cc.iN�ed conv�s hc�eby furnishr.d. a Cerrified cooy�s f�ir.d with�he co�nry buildi�g in•.pec. FOR APPLICANT TO FILL IN ADCR�NS f�lY�T�' 5 liondeporiment. nU:ICING S" � /1O U�� y�, � � on � p ACDRF55 I J C. IOCAUiV S/ f 7� Dare Applicanl / � NFAREST CERTIFICATE OF EXEh1PT10N FR0.5A Vo'ORKERS' CITV � /� � ��21P �p J [4C55 ST. CO:'PENSATION INSURANCE / S�ZE CF n55E550R T4ACT1�Cl IOi LOT NO. MnP p�ipK PAGE FARCEL �This socfion nasd nof bo tompl�led il th�pormll It ler o�a p iE USE 20'�' MF�F . hundrad dollars(S100)or lec�.) - � ON:r�[4 1— /L N Q�' �j d�i NO. I cenify+ha�in�he pr.�(ormance of i6e we�4 for which ih�s �+ . SMCint - pr.�mil is issued,I shall not employ o�y pnrson in ony monne� /+DDFE55 �J � � CONDITIONS So as�o b^cnme su6ject Io t�ir.Wer4ers'Comp.+ns '' Lpws. � �/ piSTR'Ci SIAIiSiiCAI C1A55 i1'Pf F?pCE55C0 flY Q / ��'�J CITY � /` � Z�P CONST. paie//�� o r Applicanl � ARCHITECTOR �t rE� ClA5SN0. NOTICE��O/���'IICANT: li, o(�=r mokinq rhis .i(ica�r. o( fNGiNEFR r"l� s NO. 1 •�, Err.mp�ion, you-should'bRcome subiea � e Worke�s' VAWATION Compensnlion prcvisions of�hc Labcr Codc,you must for�h- l.CCBF55 �Ei O VALIOATION with cemply wilh SULFI �fOV15�0�5 or this p^rmil shall Fe CONTRACTCR Q � N� � '� � s �' d�emed rr.vo4ed. /� - LICENSED CONTRACTO45 DECIARATIOV nCC2E55 F�Z f LSC�O. Q�Q O 3 I hereby nf(t.�„ihoi I om I�cr.nsed undcr provisions ef Chap+er 9 � ��� S � .,(commennnq w�ih Sec��en 7CYJ0�o(D���sfen 7 of ihe Business ��T� C�n55 � J � � � � - and Prnlr,ssions Code,o�d my I�cens^�s�n lull lorcr.and efloci. eE,cvivnCr�CF v:evK � � 7 J O fINAI � Uccosr.Numbnr D/�(�Lic.Class SWI�'.YING�OCI � DATE �' � } �/!� '✓�.F\ �� srn , 0.. Conlrector Dn�e FIN�I � O ❑ SO.fT. EY I am exe.my onder Sec. SRE C^ O I R.RP.C.(cr ihis rensnn EIECTRICAL U Dn�e: �-�( w . S�eel R Conduil Bonding � �- Si�na�urr, Condui�s,Conduc�ors,Equipment � N SINCLE FhMILY Z HO:!.E Ol4tiE4-RUILDER DECLARATION pLUMP,ING I hereby o�l�rm iF.nr I am e.emp�from rhe Contmtror's lkensc � . law(or Ihe fcl�owinq reason(Section 7071.5,8usiness ond P-Trop :t� .;+'�� f� Prof^ssions Cadr.)� Gas System � I,os owner o(�he properry,will do�he plum6ing and Anii-Syphon � • • • •2� ele.c��ical we�k.I,o�my Pmploye=5 wiih wa�es os lhe�r sele compensation,or a licensed coniraclo�wiil do all 1.�ECHANICAI � •+ �7 G 7 8 o�Fer work and�hn s�ruc�urc is no1 iniendr.d or offered � � fcr salc(Section 70d4 68P Code�. Swimming Pool Heatnr � ' - ° " '�:7!�FTi � CCVSTRUCTION LENDING AGENCY ��p��'�_,3� I hereby affirm thot therr.is n conslruclion lending agrtncy for qp;ti1CANT TEL. Ihe perFormance of the woik(or which Ihis pormit is issurtd �rRiNt) p�p. , :'i �;r.,�,� � (Set.3097,Crv.C.�. . Le�dor's Nome ADCRFSS . _ �' � � � � �" Q i � 1GG�� LenJer's Address p,�,Fee S �e.�,��i�rt I ce�nfy ihof 1 hmr.reod�h+s onn�+�o�+on and starr.ihni th� . � above.inlormo�ion is corrort.I er.rer io comply wi!h oll County rt ` � ��%1,��W`� ordin�nces nnd Sb�n laws rr.ln�ing to huildinq, elec�rical, Issonn�n Fee �v �C mechonical ond plumb�ng conslruction,ond herehy outho�i:e ���rs�,�auon Fr.e �G� . � .e:%'�! represrtnra�ives oF ih�s Coonty ro enic� oFon �he obave• ioml FPe menrioned prc ry for i cction pu�posas. . t � S��a;;,i�cn� , nqe�r n SEE REVERSE FOR FXPUNATORY LANGUAGE (1 � — - = C1 "' D � (1 f� " 2 -1 ^� � �O � N m N A O y ^D "� C y + n y `y D O O (� n O O O 'r � � � � G1 � �^, -i - r`�. m v� Z Z � D _ 7 � � N A N A �y z � � ~ p �I OA� IA n V r 'y rn 0 � � .s y Q y � �� m � \ I�1 Q �iO Z .Q � fl �o :� m r� � 7c � V. C' S' 1�'1 N � y (1 T T m � V (1 � � � D n D I�� ~ "� � .. t' p o � �O < Z � c =� z� �� � � \ r�• � V `. 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