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HomeMy WebLinkAbout1647A 3110A (9) V/OR!�ERS'W".'PENSATION DECLARATION ,� I harnhy�aHirm ih�t I ha�o a ce�i�ficnrn o1 cc�seni eo+elf {� inSV�P,�f 0 CC�hfi�pin o,,.,o,��,s�om���S���o���5�,��«, APPUCATtON FOR COMBINATION SWIMMING POOL PERMIT � cr a cenif�r.d cepy�hrr�a((Src.3800,lob.C.) ,�:.�y^.� . cc�:s��e,i Policy No. Company COUNTY OF LOS ANGELES BU�LDING AND SAFETY � � CeniGcd mpy is hereby fornished. ❑ CU�ID'NG Cr.•r+ind copy�s liled�.�rh i�e couniy bu�id��g�mpea FOR APPLICANT TO FILL IN noo�.E55 z S�( ��7�� � lion�lP.�nrtm=nl. BURD"�'C �'7 S21 cTE�RE CNASE ��1�1C1�� ��. ACC4'.55 (.r IOCAIITV pclr Applicant I n � r1 '"� � �J NFPRESi �\���/' t f1 1'� � ' {� CERTIFIC/1TE OF EXE.'.'+PTICN F40111VORKERS' CiTv �1'1��V IiP J ` CRO55 57. f'T �o�-{/ �;-�Q i-1 CO'.".PENSATIOY INSURAM10E �J. lJ�� SiZEO� '� .455ESSOd !RACT �"�J LOi lOi NO. M.AP 9(K'C PPGC PAvCEL (Thl�f�Nien n�ed nof 6�compl�led if th�pormN le for one `1 lEL `l � USE 2Cn;E M.1r hundred do��en(f100)or I���.) O:vNER � � � 1�,J No.`�L� �• �_( NO. O ~" I cerfify rh��in ihr perlormancc f�h^ �ak QQQ '('hi<h ihls - i SFfC�AI permfl is issu�d,I sF.�ll not vmploy:.�y p, snn ir�n�i�menner ACCRE55 �- � ���� 0 CCN91TICN5 so os fio be omr uFjccr to rhe 1Yc}k�. i mperkn ion lm�A � 1 (" D! fRl�l SIAf1511CF1 C{A55 T1'PF F�CCE55'.D�Y IO �J ;�-. J r�. ��TY '�_L�z�P �. �_ CONST. _ _�pp�e 1 1 %..plicoN _ � `�J nRCN�TFCT C7 iEL.L_71 �^ ) Qn�5T5 NO. �I �� NOTICE O A?IICANT: IF, af�e. moking rhi Cer�ifico�e ol[ fNG:tiEF4 _ - � NO.C��U��G 1 V ) ��� E+emplion, ynu shoold becomc subjncl � �hr. N/crkcrs' pDCaC55 ~1!-�J � VAWAT�ON Compensa�'�on provivons of ihe tobor Cod.. you mus�fonh- "� o+-- ��C„�O'� VAUDATION with comply wilh such provisio�s or ihis permi� sholl b� ^r(; �_(_�t?riW�E��/��7'7 S I de�mr.d�e�o4��. CONTRACTO� �•v 1- �-7L^ �`DV 'X. IICENSED CONTRACTORS CFCLAR�ITICN '� ��`' 4CDCESS � I � NO. Y�L- 1 hrrebY alfirm�hnl I am Ilcnnsed v^de.provisions ci Chop+e.o � i�C. ^ _ ''r� �i�I�. (co�.+r*+enc�ng wi+h Secr�on 7000)o(D�vision 3 0(the Ous�ness ��T� �.C7 � ����r- CIF<5 •s end Professians Cod=,ond my Gc�nse h�n fuil fercr and e(IecL �i� � ' •�� C'SCvi•110N CF 1!'C�K FINAL � Licensr,Numbrr,�� �` ._lic.Gass ���� S:7i:'!+`.'NG i'OOl � O�TE 3-7—�� , � ' ��'a r 7 �}�' r����G.-�! . � 1 T S?A � FINAI • � :,,;.`f ( � Controdo PB�h.! SQ FT. ��O y y �j�f • s '• I � �an,e,emn�undr.r 5=c. 51Ze � 7�.I il-;�1 L� B.RP.C.fcr i rrnson O �+ ,� �� � ELECTR!CAL ��J • ,/fJ�^ V _U ��? Da�n_� � �X /'� � W S� naiu�c �— S�eel R fo�d�,�t Bo�d�ng zSFb 7 9 ( • C00(IVi15,COIIf�uC10B.EQUi�JmCfll � � � SWGIE F :".RY - HO:'.E OWNCR�6l11L ER DECIARATION . L'LU!dR1YG ��� � . I he��hy affrm!hc�I om exempt Iror�the Co��rado�'s lrccrs� ' low for rh�fnlicwtnq r��sr�([••c!�cn 7p31.5, 3usiress ond '�✓ vrofes<ions Codr.l' P.Lop • Gas Sys!em `� ''`'� �.G'n � �,as owne•et t��c prcper�y,will rlo Ihc pl�mbing nnd Anii-$yphon �/ � c�^c�rical wa�k.I,o�my emr.�oyees wi!h wnqes as thcir '�� ° 'J`� solr,comprtnsoiion,cr a Ilcrtr+sed contractcr wf�l do all MECHANICAL ' _ o�her wo�4 ard�ha s!roUore is no�intended or oNercd � � °..G� :C for snl��Src�+on 7044 P!t?Ceds). Sw�mrninq pool Nca�r,r _ _ COVSTRUC710!J LENDING AGEtiCY ' a � �' •- 7.�� I hnrnby affirm�hoi iherr.is a mns��ut!ion Innd�nq oqency for pp�ICA1JT � TCL. � ��� 1�,C l�R'] ihr pc�formn�re of�hc work for wh�ch this p^rm�t is�ssucd �pRINT� r�.�-��� �+0. , ISec.3097,C��.C.) �7 �'�J� ) Ilendrr's Nomr. AOCRE55 <i� � I-11f-�IT l;�a?`+CL� � � lender's ndJ�ess p.C.i�,5 6 vr,mu Fee "2�'�'� I cerhfy ihai I hnve read this opnllcn��nn�nd srare rhn�ihr. - obove inlormnlion is[o�rec�.I ogree�o com{�ly with�II Couniy �D-�.�1 pI1CC5 and Sto�e lows rrin�in9 �o huilding, elydricol, issonnceFee n I honicnl n plumb�ng cons��uction,nnd he+rrby nuihorire �"••�`i���on F�n rep �rn�o+iv s af th Counly lo cNc. upnn Ihc obovr- io�ol frtn ��.s•S U I me n �eJ p .p rt��incnec�i�n po�po�s. � - t'ty � 'S 7 � S�p�niu.e c� pnl�caoi or ngn�i Dn�e SEE REVERSE FOR EXPLANATORY IANGUAGE � z o . o .. r a � -�+ O � f'� p P ,m„ fl —� ` � O � � r � � ,� x � ^' � � � � � � V Z � 9' p i- � U a n -�i '" 7° � Z C �l � O �^ � 'V C� � � C I'+ T A j m ~ V -��. fT� ^ Q � N � � n � Z n � 17n C N � O n T � � x O � -' r" -`- ,n � O o' � O 2 A � XI g 2 ?: t�1 ti A ��' .zi N G 7 .. 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