HomeMy WebLinkAbout0924A 1167A (5) WORKERS'CO.M�hEN5A710N DECLnRATiON �. �
;�;�;ohor orcer�ificatir of Work:rsrlCom,pensotion Ins�rnncr.f APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a ccrrlfi=d 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 f�rn�shed.
FOR APPLICANT TO FILL IN au•�o�tic
aCenified tepy is(iled w�th�he couniy bolld�ng inspec- nDDRESfi E.ieJ �a-
lion deParimenl. DU4DING (p[A�ITv ./�
a��QEsS 3�Ft �E ,� Ar�
Oa'e Appli[ant NEARFST �`�
CERTIFICATE OF EXEMPTION FROM WORKERS' CiTv (, ZiP 1 ��t055 ST•
COM7Eh5AT10N iNSURANCE SiZE CP ASSESSOQ
iRACT LOT IOT NO. MAP BOOK PPGE PARCEI
(Thf��artion nMd not bo compl�fad if th�p�rmif le for one Ifl. USE ZONE MAP �
hundrad doliors(S100f or 1�►�.) � O'::NE3 � 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 persnn in ony mnnncr PD��E55 (�F'TacJ � CO�+DII�CNS
so as�o becomr.subjec��o fhn.Wo�kcrs'Compensafion Laws. DISiRiQ SIATISTICAL QAS$ ri / wtOCe D Bv
��T� v,c..au� cA�Y Z�P 9��89 ` �
CLASS NO�
pa�p Applicont ARCHIi[CiC4 TFL �
NOTICE TO APFLICANT: It, aHer making Ihis Cerlih[a'e of ENG�tirEa 1�t (,� NO. -
Exemptien, you should become subject to the Vlnrkers' � VALUATION
Cnmpensation provisions o(tha Labcr Codc,ynu musl(orlh- FDCRESS s . ,tii� YALIDASION
idi conipiy wi�n sucii provisio�s Or �nis p^rmil sFnii be �+� T°�' ���
deemed reveked. CO'JiRnCTOR Jul� U(v�2 h0.
UCENSED CONTRACTORS GECLARATION ��`�
ecCR[S$ "'o' S
I hereby r.ffirm Iha�I om li[^ns?d unde�provisions of Chap'cr 9 �i�,
�cor�m=n:in�wilh Se[lion 7000)cf Division�o(the Business CI7Y ClASS }
�nd Professions Cod�,ond my licene�is in full 1e�cc ond ef(ect. a
CESCC'PT!C4 C'N'ORK HNI.L �
lice�se Number L�a C�ass 5'.VIY.V.!VG I'OOl � 1 /� ,Cf�� , V
�ATF ���C.` �
}�/{' �-l�"�.:i r1 �
SPA jG� FINAL �"'
Con�rodor Dala sQ.Ft. / ex ����' / � _a s . ��� �
i
� I nm cecmpl under$ra 54E I �,�� :.��� Z
i B.8P.C.ior�6iz rea:on EIECTRICAL �����J�/���'�� _ `
%
Da'^: � . .. . . .._�
I S�eel B Conduir Bonding
i S�gno�urc ConduiK,Conducfors,Eqoipment ;; !,„,.—j�;.
51NGLE FAI.11lY
I HO.'.'E O\'lkER-6UILDER CEQARnTION PIU."."BING /f�
i I hcreby affirm th^t I am e.empt(rom Ihe Contmcbr's l�censc �/ �� / .1 ��}YX� �
Law!or ihe fcllowing reason(Se:fion 7031.5, Bus�nrtss a�d P-Trop h— ���'�
I Prc!r<sio�s Codc�: 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 nGFNCY
I hereby aBirm iho��he�e iz m m�shuclion Iending ogency for AroIiCANT r. p TEL � " � • ° �-
ihc periormanrn of ihc wak 1cr which this pe�mii is issoed (ppiNT)�QSE�y{ �,f J , .
ISec.3097,Civ.C.�. p.[� wV 1 /�/� i ° � .. � , v
lender's N�me ADDpE55�p 6 •^'`��/�1 7J.'C � •
ni �. .... .,..
lendr.r's Addre55 7 C Fen S � Pr.ma Fo� -J, � I.� /—'.,
I cerliiy fhol I have rend�his applim�ion and sta�n iha�ihe �
o6ove�n(o�ma��on i:cerrect.1 agree to comply w�ih oll Coon�y issu ce Fre
ordinonces ond S�alc lows rclaiing io building, r.l�clritol, °� .
mechanicol and plumbing conshudion,ond here6y au�horire �^°"s�'9�'�on Fee �
represen!�lives of ihis CooNy lo eMcr upon �he r,bove- Tornl F .
men�ioned proper�y Ior in.p�ction purpos=s.
� �— �� OS'
� S�q�a• r oi •pi�rm o.agem Dn+e SEE RE4ERSE FOR FXPLANATORY LANGUAGE
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