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HomeMy WebLinkAbout0924A 1167A WORKERS'CO.M�PENSA710N DECLnRATiON �. � ;�;�,ohor arcer�ifimt�e of Work:rsrlCom,penso ion Inwrnncef APPLICATION FOR COMBINATION SWIMMING POOL PERMIT or a cerrlfied cepy thr.�r.of(Set.?900.Lab.C.) 76n700 CE-875(11i81) Policy No. Company � • COUNTV OF l05 ANGELES BUILDING AND SAFETY � Ce�nfied cepy is hr..eby/�rn�shed. FOR APPUCANT TO FILL IN au•�o��.c aCenified tepy is(iled with the coun�y boilding inspec- nDDRESfi EjeJ �a- lion deparlmenl. �U�tGING (p[A�IT� ./� a��QEsS 3�Ft �E ,� Ar� OO'P ApPIICOn� NEARFST � CERTIFICATE OF EXEMPTION FROM WORKERS' CiTv (, ZiP 1 ��t055 ST• COM7Eh5AT10N iNSURANCE SiZE CP ASSESSOQ iRACT LOT lOT NO. MAP BOOK PPGE PARCEI (Thf��artion nMd not bo compl�fad if th�p�rmif le for ona Ifl. USE ZONE MAP � hundrad dollors(S100f or i�►�.) � O'::NE7 � y' �' NO.� NO. —� I cr.r�Hy that in thr,performance of ihe wer4 fo�which fhis . S�ECir,i permi�is i�sued,I shnll nci employ any perzon in ony mnnner PD�aE55 (�F'TacJ � COraDtt�CraS so as�o becomr.subjec��o fhn.Wo�kcrs'Compensafion Laws. DISTRiCT SIATISTiCAL QASS 1Y / PROCE D BY ��T., v,c..,�u� cA�Y Z�P 9��89 � rF� � CLASS NO� pa�p Applicant ARCHIi[CiC4 _ NOTICE TO APFLICANT: It, ofter making Ihis Cerlih[a'e of ENG�tirEa 1�t (,� NO. Exemptien, you should become subject to the VJnrkers' � VALUATION Cnmpensafion provisions o(tha la6cr Codc,yau musl(orlh- FDCRESS s . ,tii\ YALIDASION idi comp�y wi�n such provisio�s Or �nis p^rmil sFnii be �+� T°�' v�'' deemed reveked. CO'JSRnCTOR Jul� U(��2 h0. UCENSED CONTRACTORS GECLARATION ��`� ACcaCSS h�� S I hereby r.ffirm Ihat I om li[^ns?d unde�provisions of Cha�'cr 9 ���, �cor�m=n:in�wilh Sr.tlion 7D00)cf Division�o(the Business CI7Y ClASS } �nd Professians Cod�,ond my licene�is in full 1e�cc ond ef(ect. a CESCC'PT!C4 C'V.'ORK HNI.L � l�ce�se Number L�a C�ass 5'.VIY.V.!VG I'OOl � 1 /� ,Cf�� , V �ATE ���C.` � }�/{' .-l�:'�.:i r1 � SPA jG� FINAL �"' Conlmdor Dala SQ.FT. / ex 'r��' , � -a • • ^�1 � i � I nm cecmpl under$ra 54E ' ',•_� :.^ . Z i B.8P.C.for�tiie rea:on EIECTRICAL �����J�/���'�� ..,.f,..:;_ %Da'^: � . .. . . .._� I S�eel&Conduir Bonding i Signolurc ConduiK,Conducfors,Eqoipment ;; ':,„�'—j�;. 51NGLE FA1.111Y I HO.'.'E O\'lkER-6UILDER CEQARnTION PIU."."BING I hcreby affirm th^t I om evempt(rom Ihe Co��mdor's licensc �� �� � ���� � ILaw!or ihe fcllowing reason(Se:�ion 7031.5, Bus�nnss a�d P-Trop I Prc!r<sio�s Code�: Gas Sysf�m �� �] � 1,ns ownrr of tF.n prcpPrry.w�ll do ttie plu^�bing c^d Pnti-Sy^hen o'✓�?� � i elec���cal wark.I,or my empieyees wiih wcgPs ns�heir sale comp^nsoiion,or a Ifce.nsed ron�raUor will do oll h'.ECHANICAI o�h>r work ond Ihr.s'ruclu�r.is nol in��ndPd or offe�ed for so�e�Section 704d BRP Cadr.). Swimming Pool Hr.a�er . . � 1 ; - CONSTRUCTION IENDING AGFNCY I hereby aBirm iho�ihe�e is m m�shuclion Iending oge�cy for AroIiCANT r. p TEL � " � • ° �- ihc periormanrn of ihc wak 1cr which this pe�mii is issoed (ppiNT)�QSE�r{ �J J , . ISec.30D7,Civ.C.�. p.[� wV /�/� i ° � .. � , v lende.r's N�me ADDUE55�p 6 •^'v��/J IJ.'C � • � i .. .... .,.. lendr,r's Addre55 v C Fen S � Pr.ma Fo� /r � I.� /— ., I cerliiy fhol I have rend�his applim�ion and sta�n iha�ihe � a6ove in(ormv�ion is cerrect.1 agree to comply wi�h oll Coonry issu ce Fre ordinonces ond S�alc lows rclating io building, r.lrtclritol, °� . mechnnical ond plumbing conshudion,ond here6y au�horire �^°"s�'9�'�on Fen � represen!�lives of ihis Coonry io eMcr upon �he r,bove- Tornl F . men�ioned proper�y Ior in.p�ction purpos=s. �( �— �� OS � S�q�a• r oi •pi�rn� o.age�i Dn+e SEE REVERSE FOR EXPLANATORY LANGUAGE � � n - � 'n - — -'� T -- �• - ��-— ------ -��-r- - — n -• C1 � ., ! � n _' n � fn -. � ' O u� y ^. C :r n n = �.; -�i N � I �' � �i fl I C O n C1 �' ' - r �, {..� , ' O � N n � �' ,.._ ~ •' A ^ _ C: C7 -� .� I ___ < C : A Q' C) . D' ;� p y � �.. n'� � - : � (1 O O - . 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