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
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