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 .
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