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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 . (:', � � '' � U ; �� n y -- ^ � N p — —� � L' � n r--- — - � o v. � c_ � � � c o � - " C� m ,'�' -< - c f-� � : � 0 ^ � � v� N T: z U � (J � �" � I � r 0 fl � ��I ^ ;� � . 1 I " I � � U � � � I ..' n n -� ai n� Ll () I I �,j a: ", i . 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