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
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