HomeMy WebLinkAbout1341A 1342A (7) 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. .
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