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HomeMy WebLinkAbout0862A 1729A f •�. '_ '� ,�• ' t ' ._.. _ � � .:��:',aT�CN GELLAR4TiC�N �, � �„�',`;�`;',.°",-°""`"°`"°``°��.'•"'- 'r•� APPUCATtON FOR C ��TION SWIMMING POOL PERNIIT ',, or n ccrtl�ico�•.o kcrs'Comp••ns:.•':�n!-•c,�rct. o«�°ed cr.oY th"•"e (S^c.3F'b.L�b.C.) �u,arC •.�.� cea;c a�ea L �No.�=—Cempany COUNTY OF l05 A . .�� BUILDING AND$AFETY P��"��c �rr6 furni..hed. r r� r�ifind cop!15' Y / L j L� ,filr.d w�+h ihr,co�n�y building inspec- FOR APPLICANT TO FILL IN ADDRE55 �`S^�t� �—G l%�- �- , o �F,,,�,���Pc,�1. BU4Di•:G tion d^.[`"�" PDDRESS 1('� � , LOCAIITY � n�P����^� • � NFAREST Do��� [ITY ZIP �RO55 5T. /CEPTIFI��ITE CF EXEMPTICN FROM WCRKERS' ' SiZ c;F n55c55eR / 1:O:MPENSATION INSUQAtvCE TIinCT l LOT ti0. M.AP P.00K PAGE PAPCEL i saNianfwad not ba complel�d i(�Fa parmif t�for ona ��/ T[�. u Ca_ r,�ap `/ ndrod do/ars(5�00)o�Ies�.) O'h'NER ��'. (/L/ � /� n:0. Q �P�J n0. ��y��7�g I cora[y iN.�in ihe per{ormoncmeF the work for which�his ' h_ � SFECIAL . � . � perni�is rwed,I sh�ll no�employ any person in ony manner ACDQFSS o��ryv-U CONDITICN$ so ns�c F��come subi"<<�o the 19or4ers'Campensa�ion lows. � D157PICT SIAIiSTICAL C1A55 TYPE FROCESSE�Br ' CITY Zm � CLn55 NO. COtiST. Dn�e� Applicant AOCMi7EGi O l. ,�y� I nCTICE TO AP7L�C'ANT� IF, a1�=r m;kinq th�s CPrlilicate o� fNGiNEER G �.NO "W /V �� � �9•. Exer�.p!ir.n, y�u sho�l�i b^con+e. subjr.ct l0 1he Workers' �DO�E55 � � YALUATION Co•no�nso�ion�rovisions cf thr..lnbor Codn,you must Icr!h- VALIDA710N wii4 comply Wth such provisions or �his permd shnll hc O S �Acemrd rev�4rd. CCNixaC70R �� �_ �i �� �ICENSED CONTRACTORS DECIARA710P1 qppar,SS � � NO. . O�F.i i4 I hemby o����m�hot I om licensrd under provisions of Chople�9 ��� f ' (commencing wph S=c�ion 7000)c(Drvisicn 3 nf rhn Busin�ss ��Ty GLASS � � • • ;�� and ProfezSinrts Cod^,ond my license is in Full form nnd nffed. CFSCQ��iiON CF wO�K '. • � FINAL � f �a��-" Licens^Numbr.r L�t.Cf�ss SWY;.l!:NG I'OQL DATF � `�`� Conlroctor Da!^ ��A FINAL * ' ••�'•,•,.-. O � SO f t — U I nm c•ampl undrr Se=.__, 5lZE � �Y ��t =U'C U � .. O 6.RP.C.{er ihis rcason^..._ n U EIECTRiCnL y7 /�/7 � Do1r.: ' q..�[ (/•�"-� . W I Sieei R Conduit Bvndin9 � n- Si�no�we. Condui�s,Condoctcrs,Eqvipment � z SINGLE FA�11LY �s��- _ HO�..E O`.N4ER�IlUII�ER CECLARATION P�U'�911G �7, �. I Mreby oSlirm!ho�1 om e�ompt from Ihe Comrnctor's license � S �},,,;�t' 6-�'"���'�` 7 (nw(or the fvllowing reosvn($ec!icn 7031.5, 9vsiness ond Z�'w"'- P-Tr�� Professie� ndel� . � � Gas Sys�em I,as owncr o(ih�prc�erty,will do thr,plumbing ard 1n�i�Syphon electrical work.I,or my rmploye^s wiih wages as t6efr sniP comp�nsn�ion,or o li:ensed c�n!rocter will do all MECHANICAL o�her work ond ihn s+ruc�urn.is noi in+ended o�oflered . �� /2.g� for salr,(Section 704•f BRP Code). Swimming Pool H=n�er • � •.e J COUSTRUCTIC"J IFNDING nGENCY " I hereby afh�m ihnt�here�s a mns'ruct�on lend�nq ngency For Am��� C r�� A � 1 0�G�Jr O ihe pr.rformnncn oI�he werk for wh�ch if�is permlt is iswod (pR1N7} �� �! (Sec.J097.Civ.C.). , S �'c .,=c;n�a� � lendrr'S Nomc n�CpESS IJq � Qr,'.Q.Qi"�'C I I•nder's�dd�ess P.C.Fer S ��3 Prrm�i F�e / ( �•� ' ! ��r1dy 1ha1 I hav�rcod ihis applicalion ond sratr.Ihol the M � !ove informotion is cormd.I nqree to comply with oll Counry r O-J V �finonces nnd S�n!e Inws relor,nq to huildinq, eleUriml, Iswance Fe� �rh�nirnl nnd plvmb�n cons�.utlian,and hpreby oWhori:e Inveseqnnon�rr �O O:r . . +xea c f �hi �un� b enrpr on thn ebave- TMoI fert J n�� hrr r�y 1 i 1= c � � � s,��n����o n�noni,m;,�n�n�r�i D � SEE REVERSE POR E%PLANATORY IANGUAGF .. 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