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HomeMy WebLinkAbout1448A 1710A (8) • �• . ; 1YORKERS'CO�".PENSATICN DECLARATION , � � I herr.by af(�rm��,a�� �o���«��;F;���A oF�o�=P�������f APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � insu�e,or o ceruficate cl�'lr.rkeri Com enza�ion Insuranco, � or a ceri�!ied copv ihareof(Sec 38Q0.Lnb.C.) 7en1^e ��J�1_ , G'A75111/81) Policy No.�.���Campany ������' �ti��J COUNTY OF LOS ANGELES BUILDING AND SAFETY � Ce�rfied may�s herrby fwnished. � FOR APPLICA O FILL IN ^u,io��:c CPrlified topy i5 IIIPfI with ihe coun!y buildin�ins�et• ACDaE55 :ls�3r lion[�epar!mP.nt. eUItO�NG �^ � ��lTT77Y4�r A��aE55�J.3 � LOC.ALITY Do�e "" �` �+pP���ant � NiAREST CITY 21? CRpSS S7. CERTIFICATE OF E7fEMe TION FROM WORKERS' SiZE O° ASSf55C7 COMPFNSAT�ONINSUQAIvCE iR�CT 33s3 lOT LOTNp. II MA�e00K PAGE PARCEL (This aadion nsad nof 6�cemple��d ii 1h�p�rmit Is For on� iCL. y� USE ON NAP Q`�'�3�', bund�ed dollars(5100)or lase.) 0•+:hER NO. �—� n%O. I cenify ihat in rh�pe�fo�moncr,ei ttir.wer4 tor which th�s . ��Q�� 5=cani permil is issued,I sholl not rmploy ony person in any monner !•CC�E55 COtiDITICNS so as�a becomr.subiP����ihe Workcrs'CemA�nsation Lows. C�S:�iCT Sf�1ISTiCnL CInSS , TrPE FAOCCSSED Br CITV Z�' / ClASS NO ��ST. Datn Applicmm �RCHITECT a TFL �O /0 ' ' 3% , NOTICE TO APr"LICANT: If, afrer moking this Cer�ificn�e of ENC'vE. C� : Exr.r�,^.iion, yau should br.come SJ��PC� �o �hn VJnrkers' � � VALUAiiON � Comp�nso��an�rovisio�s of t�,c labor Code,you musl fo��h- AD�pESS �j �I' Q j lF�. y� /y� YAIICATiON wi�h mmply with such p.ovisiens cr !his pmmf� sFvll be CCNTRnCi /Lf�/ � ��7 s � w � dr�med reve4c�1. � , . LICENSCO CCNTRACTCRS CECL�RAiION ��`' �� � necF:ss�3� ..J � No�� - . I hereby offirm ihat I am litensed under provisions ef Chopter 9 ��� s � (cemmencing wi!h Seci�en 7CYJ0)of Div�sion 3 of ihc P.us�nes: �i. C�nSS } ' �nd Fro�r.ssens Calr.,ond my license is in Iull ferc^CO(j PHACi. � � � C�SCR"IICV CF V;CGK I--� FINAL , �'� �`��•���^� � �1I^y� c� v ' llcense.N�m nr ��v'�'� Li[.Cl�ss� S`.':I:•;1'VG POCI LJ DA7E JZ('}�c."C7 '. • • e •7� � ' " O .i'�— Dolr, �rA � FINAL � • •�v 2.F)1 v Con�ract SC]Fi. (�y�}� ■Y . • W � I�m r.xempl unde•cc:, SiZE .J�v � . •.,.. R.RV.C.(o�rhis rrtoson FIECTAICAL �' G �'.5 ct �����.: rG��.,�..._ r., � z �"r.1 � o���: � 5'eel B Conduit Bondin� � S�q^aN�r. Co�du�ts,Conductors,Eq�ipmeN S�NGLE FA.lILY NO'."E OVJNER�P.U!LCER CECLARATION FlU""�"ING , • I hereby olKrm thot I am e�cr+pt fror�+tio Coniroc�or's L�ce^sr, . :=� � �.U r� Lnw lo•�h!e followint�rrnxon IS�c�io�70J1.5. Aus�ness a^d p.Trop � , Fro(ess�ons Cede): Gr.s S stem '� � � � � �`� ( Y - � I,ns own=r of!tio prcp�r�y,w�ll do ihe plumbinq nnd AMi-Syphon , electrical wcrk.I,o�my employcas�vith wn�^s ns the�r _ f � � �"���' saie compensa��on,or o Gcensnd contrac�or wlll do oll Y.ECHANICAI „ c'her wo�k nnd tkc strocturrt is no�in'Cnded or of(cred , � � ��"�G� {�..�I�(c„c�ion 7044 AdP CcJc). Swimming Pool Hra�rtr �� . . .. 07._G-&:5 CONSTRUCTION LENDING AGENCY ' I hc.r.by aff�rm iho�ttirrr.is a cons�ruc��on Ic�dint�a9nncy fer pp��CA�:T T[�. ihe pr.rio�r�once ot the work Ier wh�ch�h�s perr�ir rs issued �FR�yT� h0. , � (S�c.3�77,C�..C.). Lrnder's Nom� ACD4f55 ' . LC�f�C��s AdJre55 P.C.��e S v�'O/ verm�i Fee � /�S� ' . . I certify IhN I hove r�ad ihis npolication ond s•a!r. thot the . ( � � � above in(orm��io��s co�rec�.I og�ee�o comply with�II Counly Issuance Fen �Q" �.7� ordinonces ond 5'n!e lows rr.latin�to bo�id��g, eiecv�coi, mechonicol nnd plumb�nq mns�ruciion,�nd herrtby auiho�ire �^°^si�qa��on Fee / Q e D D reP��'sen�o�i�es ol ihis County io CnIPr upon the n6ove- io�al fc- CJ O , . . men�ioned p�operty For inspeci�on purpeses. � S,q„�a .., � .,n,;��i po�e SEE REVERSE FOR E%PLANATORY LANGUAGE . � � ° � � . %'R = -� � , �' � % � p �� � ��G. n �^ [� � �� 1.� � f :a ! , �'� C� O i\ �� O O � �'� 1\ � �. ..: � �i ;�i\ �: �' .. r� G J � � � � �N � � � , '` � \� � r f � / � � %� 4f� 1:� , ` ` ` � //� � (� � i \ N f' v` i �� + \ 1 \ ;i� ` O _ , % C \.� - 'ti \ � /' o � �, r � �, �G.�. �; �L . �\ .l...,- .Z'.. . (\�` O �. � M �. 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