HomeMy WebLinkAbout1164A 1284A V/02KERS'CO:',r•ENSATIO'J DECIARATiON � � �
I hereby affirm thni I h�ve n cr.rilfica�e oi consem�o snl! " �
insurr.,or a ce�i�ficolA nf l'Jorkers'Compensa�ion��,�,a��e, tiPPLICATION FOR COMBINATION SWIMMfNG POOL PERMIT
or a cen:fied copy therecF(Sec.J!300,Lnb.C.) 75qr+e
CF.�875(I1/A1)
Polky No. Company COUN7Y OF LOS ANGELES BUILDING AND SAFETY
� CerPfied cepy is he•eby iurnfshed. -
� Cr�tiGed ce s ii�ed wnh�hn coum bu�ld�n ins FOR APPLICANT TO FILL IN t+uno�r�o c � .
PY� Y 9 P^t- AD�GESS I�I J . R 4r�— Trf-
lion deprn�mrnt. RUILCIVG � n -
ncc,�ss r��f ccC !/�f:�_ c7/4._ iocnim _J"7 •'
Date f pplicant
CERTIFICATE OF EXEMPTION fROM WORKERS' ��TY m` ��flC. Z�� Ca055 Si. r •
CO.MPENSATICN INSURAN:E �(' �1 SIZE CF n55;5S6¢
TRACT �� u LOi LOT NO. 3 N.AP BOOK PAGE PA4CEL
(This��c11on n��d nof b�cemplefad ii th�parmit It foi one !1 iEl. (� u5E ZC�.E Ma❑ rv G
hundred dallari(SI00)or I�sf.) Oe�ti•ER ��e+1� G' nO.J /'�'r7T NO. O � � ��
I ceril(y ihet in the perfo•mr.�c=e(!he wo.k lor which ih�s , c��i�i
�=,m�r+.�..ord,i shall not empl�Y pny Fa��on in r.ny monner r.r.ecess /S—!<t .S�/�µc£_ Yr�E� �'!�• CGhDITIONS
so as�o become subject�o the 1Nor6ers'Campe�5a:�o�Lnwz. �(� CISiR:[T STAiIS11�At CLA55 IYPE PROCFSSFD BY '
[ITV C`J��/�T�• � ZIP �v COVST, •
Dalc ApD�i[onl AR{IiIiFCT OQ TF� CIASS Np. �/
NOTICE TO�1FPlICANT: If, of�er mo4in� this Certi(icate a( «�:'`'�ER n�0.
E.r.mp!�on, you should f:ecome suF.jeU �o thr. 14erkers' VAWATION
Campensation provisio�s c(Ihe Icbor Codr,yo�musl(crlh- A��4ES5
with comply with such provisions or iti�s permii shall bn � � TE�. s . VALIDATION
�lr�mrcl rrvc4ed. CCNin'RCTCR C/j-L. r �No��7 S??� �3 e.h v^ea .
LICENSED CONT2ACT0R5 D'cCIARATION /� /� ���� �7���y �
A,DCGESS —/�SF.j' /L•R�C.t.�`.S)_h0. I � . '
I hcrehy oFFirm�hn�I�m licens2d onder provisions eF Chrr er 9 ��� S . ,
(commen:�ng w�•h Sncr�on 7000)of D��isien 3 CI 1IIP Bus�ness CiiY �+�� Qn55 C�S y }
ond Professians Cod�,�nd rny lirensc is in full fcrcr nnd r.f!ecl. — O
CFSC�I�i!CN C'\VO4C
license Number �,F'��'�1�' �ic.Class c—� � � F�NAL
V
' S1Vi�:'.V.:^:G AGG`l �y �r DATE ► :� � h�l�i .OG
Contra:tpr Da'e �— � FINAL �� • • • o j� �
❑ 50 FT. By U
I am oecmpl undcr Sec. =.�IE � • •�F;':3 �
N
0.8P.C.for!hIs reason � CLECTRICl1L ' ' ������- _
Da!e: �
Si�na�ure _ Sieel R Conduit Aonding �� �� �7.��`—�J
Condui!s,Conduc�ors,Eq�ipment 1 �1 "� .
�5: LE FAMILY A"iC.Z�w � .
H OL':hER-9UIlCi4 DECIARATION p��;�n�nG ,
I hereby aNinn th�t I nm ener�p�fro�thr.Conbac�or's licensn �
Lnw for the followinn rr�son�Sac��nn 7031.5, Hus�r?ss r.�d p.Trnp
Prcfess�ors Cod^): � i
Gns SysMm I
� I,as awnr.r o(t!•c prcperty,will�lo th�pl�mb�ng and An�i•Syphon � �
cl��lrical wcrk.1,cr my emp!cyces wi•h woqvs cs+hcir ,:� ��i,•',�
solc ccmcrtnsaiioqor a Gcensed to�rractcr will do oll h'�ECHqhIC,1L
oi6er wrnk nnd�h�errucrore is not inir.nded er effered � ^ ^ � •j i
(or s�!rt(Srdion 70dd P.RP Codrt). Swimminq Fool Hoa�cr � � • i:-.
� � •�l,l;.;li
CONSTRUCTIONlEND!M1G f1GENCY JJ j O�a �Y� r :;':,;.,��:
I hereby oif�rr�ther th�re�s o mnsvucrion InnAinq agency Fer pntKICANT TE�. ,
ihe•pe�(ormon:e of the work for which Ihis permil is issur�l �CRINi) � Np, , i� !.j !—t :.
(Sec.3097.Civ.C.). ' .
Lnn�!cr's Nnmr. ADD4FS5
iP��.•i s Add,�s, p.C.Frn S �6 S3 �9�•v� •• .
I ccrri(y ihai I havc rvad ihis epplica�ion ond sinrc rhat ihe �e.m�rFce
r.5ovc information is co��eci.I o9rcr.�o comply wiih oll County " �Q.5"�
ordinantes and S�alc Inws rrloiin� �o bu�ldin�, elec!ricol, leevan«Fse .
mech�nicnl ond�lumbin7 consnuclion,ond hPreby ou�horiz� InvpS1�G�1�0�FC� �D ^�D
repres;�rives of �his Counly lo cnMr upon Ihe above- To�nlFpp c.i -
mPrilinn d aor.rl 1er I
pr 'y nSrrClion nurnosl`5.
� — _l� •
���..�.r oi nn:,rcc��o�n;e�� o��o SEE REVERSf FOR EXPtANATORY LANGUAGE i
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