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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 - - � � , J . - _ -t L.�, I �I_ � ��c �J Ry/� Gy-"_�.-./'����� ��r^ "' ^ " � � — �� . '�� / �� /J ��� (j� � - �, ` � � o - ��I:• � � � � �jf� i`- '� 11 :r in �' n �' 1 C1 � _ . �(� 1/1 L'�L• .,J C1 '�; n � �r: i t^ C [ Cl n U � �; � �;� I �1/.�d' fG% T "'. n � , ' ,� ., l~'`�� C7 { ' (j � h �1 y, 1 r U �- ; ! n �. 'O � � 7 T � .^� (1 T t I 1�1 1 4 � y, !l _� f � 0 � r � r� = � I � JG U � n �y � f � � I , � I yJ I'� V� �� •_ � � � r .. 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