HomeMy WebLinkAbout1448A 1710A , � .
1YORKERS'CO�".PENSATICN DECLARATION �� � �
I herr.by a��„m��,o�� �o���«,�;F;����oF�o�=P�,�o.��f qpp�ICATION FOR COMBINATION SWIMMING POOL PERMIT '
insu�e,or o ceruficate el�'lr.rkeri Compenzaiion Insuranco, �
or�cert�!ied copv ihareof(Sec 3800.Lnb.C.) 7�,�7�;g �
(i75(1 I/81�
Policy No.������mp�ny����� COUNTY OP LOS ANGELES BUILDING AND SAFETY
� Certffied coay is herrby fumished.
O Cerriied co 5 II�P!�with ihe FOR APPLICA O FILL IN ^u�io�ti�
Py i coun!y build�nq inspet• nCDaE55 �S"3r
lion depar!mnnt. BUItOiNG �^
���� Ap�fiE55�J•� / L0.AlITY
Dore " .` ApPIi[ani ^ NiAREST
CERTIFICATE OF EXEMr TION FROM WORKERS' ��TY ���^ Z�' CRCSS S7.
COMPfNSAT�ON INSUQAhCE 1 SiZE O� ASSf55C7
iRACT �35,/ lOT LOTNp. I MA�e00K PAGE PARCEL
(This aedion nMd nof b�cemplebd ii lh�p�rmil ls For on� i[i. ,�.�� u5E ON nrqp
bund�sd dollars(f100)or la��.) Ov:hrq NO. �._� r;p. 0���3,3 7
I tenify ihat in rh�perfo�moncr,ef ttie werk tor which th�s , ����� S,F�i��
permil is issucd,I Sholl not rmploy ony pprson in ony mannM l.CC�E55 COtiDITICNS
so as�o becomr.subiP�����he Workcrs Cemprnsation Lows. L'�S:�iCT Sf�1ISnUL CInSS TrPE FAOC(SSED Br
CITY ZI� - ' CON51,
Date Applicmm �cCfnTECT a TF� Q �IASS NO
NOTICE TO APr"LICANT: If, afrer moking this Cerrifim�e oi FNC'vF. (� ��ji � 3�
Exr.r�,^,iion, you should hr.comn subjPcl Io Ihn VJnrkers' � VALUAiION 1
Compenso��an provisia�s oF thc labor Code.yau musl fo•rh- p0�E5S 0, ��-
wi�h mmply with such p.ovisiens cr fhis pmmf� sFvll be lel. s /�Q VAl10ATiON !
decmr,d revckrd. CC"JTR4CT 2(+� � / `^� ;
LI�ENSCO CCNTRACTCR$CECL�RATION . . ' uC. '
I hcre6 oHiim ih�r I am I��ense '4�`F:S�� �� Np��� �
Y d under provisions ci Chnp�er 9 S -
(cemmancing wi!h Seci�en 7C�)of Div�sion 3 of ihe P.us�neSS �i. C�SS 'y
n�d Fro�r,ss�nns CotJr,�n�1 my license is in Iull ferc^r.nd eHect. ��R:'iIC'J Cf V:C�K �
II-^-�y� FINAL c�
Ucense.Nom nr ����� Lic.Gass� S`.':iY;1�VG POCI L_J DA7E J�('}��"CJ ► :'t `:i.v;/^, O '
•'j� O[ �
Conaocr .i-�-- Doie Srn � FINAI ': • • e 0
soft. }� sy j • •;,`2,Fi1 u
� I om r.xem�l unde•c..;, SIZE .,�V y,�
p !; / r � :. N
R.R�.C.fo�rhis rrtoson FIECTAICAI g (o ,Q�f [� /Ld Ca�A,y: /r(��f,G•1�...�•�.. z
o���; 0 G"r.1 , .,..
5�9„����� 5'eel B Conduit Bondin� � �
Co�duits,Conduttors,Eqvipmenl • '
S�hGLE FA:11LY
NO'."E OVJNER�P.U!LCER CECLARATION FW"'�"ING
I hnreby alfrm�hm I am e�cripi fror��tio ConlroUor's L�censr, , ' :., 7,.�r1
Lnw Iw�he followinq rrnxon ISecrio�70J1.5, Buvness o^d p.Trop
Fro(e�sstons Cede): Gr.s System � _ ,';• • . . •J 1
❑ I.ns own=r of!tio prcp�r�Y,w�ll do ihe plumb�ng nnd Anfi-SYphon ' ' 1 r�O�
e f ea r i c a l w o r k.I,o�m y r.m p l o y c as wi�h wn,es ns i he�r '
soie compensa��on,or o Gcensnd contrac�or wlll do oll P,'ECHANICAI � �
ceher wrnk nnd the 5trucrurn is nof in�ended or olfcred w . � L;.O(��
{�..�I�(c„c��on 7044 A�iP CcJc). Sw�mm�ng Pool Hra�rr �--' `
CONSTRUCTION[ENDING AGENCY � -. O�I.Z G-s+J '
I he.r.by aff�rra iho�ttirrr.is a cons�ruc��on Ic�dint�agnnty(er nv�iCnni
���e pr�fo�r+ance of rhe wor4 Icr wh;ch rh�s perr���rs i<sued T[�.
(S^c.3^77,C�v.C.). IFRWiI M1O.
�P�(SFr�S N:]rt�a ACD4fSS . , �
Lendcr'3 Address x p '7 �L '
P.C.f�o S V�•p/ Oerm��Fee / /�V� •
I certify IhN I hme r�od ihii npolication ond s•otr thot thc [—,l • �
a6ove in(orm��io�is co•recl.I ogree�o comp�y with�II Counly Issuance Fen �Q� J v
ordinances and 5'n!e lews rr.lating to boilding, elecvf�ol,
mechonicvl nnd plom6�ng cons�ruuion,nnd hnrrthy authorire �^+'^siyn�wn Fee J��, D D
rep.esen�o���es ol ih�s County io C��Pr upon the nhove- imol fc� �
men�ion�d property for inxpec��on purpeses. � � .
5'fl"�'' -� � .'�;"^� �o'e SEE REVERSE fOR EXPLANATORY LANGUAGE 1
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