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HomeMy WebLinkAbout1647A 3110A V/OR!�ERS'W".'PENSATION DECLARATION ,� I hernhy�aHirm ih�t I hn�o a cwi�ficntn o1 ce�seni eo+elf {� inSV�R,�f 0 CC�hfi�pin o,,.,o,��,s�om��nsntion��5�,���r, APPLICATtON FOR COMBINATION SWIMMING P40L PERMIT � er a cenif�r.d cepy�hr,r�a((Src.3800,lob.C.) n:nypit . cc��s��e,i Policy No. Company COUNTY OF LOS ANGELES BU�LDING AND SAFETY � � CenifJcd mpy is hereby fornished. ❑ CU�ID'NG Cr•rr�nd copy�s liled�.�rh i�e couniy bu�idi�g�nspea FOR APPLICANT TO FILL IN nooa¢55 z S�( ��7��i- � lion�lP.�nrtm=nl. BUifD"�'C �'7 S21 c�-�RE CNASE ��1�1C1�� �=�. ACC4'.55 (.r IOCAIITV pcla Applicant I n1 � r1 "� C NEPRESi �\�l�/` t f� f'� j ' � CERTIFIC�TE OF EXE"+PTICN F40ti5 1VORKER$' CiTv �1'lL��/ IiP � ` CRO55 5'. f'T t-iA-{/ e- -� CO'.".FENSATIOY INSURAM10E �J.%J�� SREO� I� .455E5504 !RACT ry->J LOi lOi NO. M.AP 9(�C PPGC PAOCEL (Thl�f�Nien n�sd nof 6�compl�led if th�p�rmN le for one `1 iFL `l I � USE 2CM1E Mnr hundred do��en(f100)or I���.) O:vNER � � 1�,J No.`�L1 �• �_( NO. O ~" I cerfify rh�t in ihe perlormancc f�h^ �ak pr'{'hi<h ihls — t SFfC�Ai permfl is issu�d,I sF.�ll not vmploy:.�y p, snn ir�n�i�menne� PCCRE55 �- � ���� 0 CCN9ITICNS so os b he omr uFjccr to the 1Yc�k�. i mpe�kn ion 1m�5. � 1 (" D! fRICI SIAf151iCFl C{A55 TY� F�CCESSFD OY fI �7 C,' � CITY ,�.�_�IP l. �- CONST. „ _�pp�e 1 1 %..plicoN _ � i" nRCN�TFCT C7 iEL.( � Qn55 NO. p �� O r�--� ._ f —]^ ) �T NOTICE O A?UCANT: IF, af�e. moking rhi Ceriifico�e of fNG:tiEE4 _ - n h0.C�-U��G 1 V ) ���� E+e�+plion, ynu shoold becomc subjncl i �F.r. N/crkcrs' pDC?[55 ~1!—�J � VAWAT�ON CompensaY�on provivons o(ihe Lobor Cod.. you must fonh- "-` o+--- ��C„�O'� VAUDATION with comply wilh such provisio�s or ihis permi� sholl b� ^r(; �_(_�t?riW�E��/��j'7 S I de�medre�oked. eerircnCtoa �•v T �-7L �`DV 'K' fICENSED CONTRACTORS CFCLAR�ITICN '� ��`' 4CD�ESS h0. L_ 1 hrrebY at(irm�hnt I am li<nnsed v^de.provisions ef Chop+e.9 I � i�C. ^ S ''r� �i�I�. (co�.+r*+enc�ng wi�h Secr�on 7000)o(D�vision 3 0(ihe Ous�ness ��T� �.C7 � ����r- CIF<5 '•s end Professians Cod=,and my lic�nse is in fuil#ercr and e(IecL �i� ' ' •�� CESC��910N CF�YC�K FINAL � licensr,Numbrr,�� �` ._Lic.Gass ���� 5:71:'!+`.'NG i'OCl � O�TE 3-7—�� , � ' ��'a C 7 � r����G.-�="'. � 1 T S?A � FINAI • � :,.:.Y (: � Controclo �Ir ��O 6 Y �y�j�� � U � 5� FT. ��/ I �a n,e,e m n�u n d r.r 5=c. size t. ��,j i l—;�j L" B.RP.C.fcr i rrnson O �` �+ ,� �� � ELECTR!CAL ��J , �� V _V ��? Daic-� � �x E{ w 5� naiu�c -- S�eel R fo�d�,�t Bo�d�ng zSFb Z 9 ( � Condous,Conduclors,fQu�pmeni V �t � SINGIE F :".ilY f — HO.'.E O\VNCR�6l11L E2 DECIARATION . L'LUIdRItiG ��� � . I he��hy affrm!hc�I om exempt 6or�the Co��rado�'s lrccrs� ' law for rh�fnlicwfnq r��sc�([•+c!�cn 7p31.5, �usirMs ond '�✓ Profes<ions Codel' P.Trop � Gas Sys+e�.+ � :•J 1 1.0,4 � �,as owne•et t��c prcper�y,will rlo Ihc pt�mb�ng n�d Anii-SyOhon L � c�^c�rical wa�k.I,o�my emr.ioyees wi!h wnqes as thcir '�� ° 'J`� solr,comprtnsoiion,ci a llcrzr+sed contractcr wf�l do all MECHANICAL ' _ o�her wo�4 and�hn s+roctore is noi intended or ollered � � °..G� :C for snl��Src�+on 7044 P!t?Ceds). Sw�mr�inq pool Nca�r,r _ _ COVSTRUC7iOv LENDING AGE�CY • a` ''"'''`� I hnrnby affirm�hai ihrrr.is a mns�rut!ion lend�nq oqency for AP^�ICANT � TCL. � �7� ��•C l�n'] ihc pc�formn�rc of�hc work for wh�ch�his p^rm�i iS�SSUCI� �GRiNT� r�.�-��� �+0. C., , �Sec.3097,G�.C.) �'7 lt��J�(.1� � Jt ILendrr's Nomr. AOCRE55 <!� I 1�-,VT �?`+Clr� � � lender's ndJ�ess p.C.i�,5 6 vr,mu Fee "2�'�'� I cerhfy ihai I hnve read this opnllm��nn�nd smre rhn�ih� — obove inlormnlion is[o�rec�.I ogree�o mmply wdh�II Counry �D-�.�1 innnces and Sto�e lows rrloring ro huilding, elydricol, issonnceFee n honicnl n plumb�ng cons��uc�ion,nnd he+rrby nuihorire �"••�'�7^^on F�n rep �?nra�iv s of �h Coun�y io cnic. opnn ihc obove- io�ol Fen ��.s.S v me n �eJ P ,p rt�f��ncnec�;�n pv�poy�s. � L - J j�t!' � � �� � Sg�niu.e c� pnl�caoi or ngn�i Dn�e SEE REVERSE FOR EXPLANATORY IANGUAGE a 4 � 0 � � i � �� O � � 7 - r a ! .n Q � � � 0 I� - ! .��1 N d � Z OA M O 'D •� e^ � G � (5 „' � � � A Z :.� � N � . 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