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. �
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