HomeMy WebLinkAbout0862A 1729A (4) 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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