HomeMy WebLinkAbout1352A 1447A (7) . _ .� .__ .._ _.--- - .
\VORKERS'COMPENSATIOy CECL4RqT10N � `�,,,
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1 here6y a(frrm ihat��,���a���,;,;«,��,«�,e�,,o,��F app���ATION FOR tOMBINATIQN SWIMMING POOL PERMIT - �
in5ure,o•a certificotn of Wnrkcrs'Compensclion Insur�ncc,
o�a certificd ccpy thercn(�54c.3900,lob:C. 76AY_`J
1�7ss'�Y � fE�275��1/fll)
aol�cy No. Company �-C�-� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� C^rtified ccpy is h��eby fumished. .
O Cr.rtif�ed ce s f�led�vl�h f.e count bv'�Id�� ns FOR APP ICANT TO FILI IN au':o:�� 1 y ,
rv� � r e� nec- �n�eess
lia�depertmcnt. /� J
� ACCRESS W�D� �
� %-� r iocnun
Da e Ap�p Icanr ' . — h�EqeESi J
� CITV 21P CROSS ST.
CERTfIlCATE OF EXE'NPTtON FRO!d tVORKERS' �q Siie oc n55E55cR
COMPENSATION INSURANCE TqqCT �'z�+ J lCT LOT k0. MAv BOCK PAGE PARCEL
(ihl���c�ien nwd nof M compl�Nd if Ihs permif Is for one �FL. L u5E ZONE hlAP
hundrad dellori(5100)ar le�s.) Ov;NF4 NO. �����G+�� No. 9"�r^ �3
I certi�V�ho�in tti^prrlermnncr,r.f�he wMk(or which Ihis
permit is issur�l,I sticll ncl em�toy ony perzon in any manner ADDGESS S�E��a�
COv�ITIC"d5
so os b 6=come subjrU to!he Wwk�rs'Comp�.tnsnlion lows. D�SIR��f STnTiSi:CAI CLn55 1vPE PROCESSED BY
CRY �� � ZIP /Q CLASSNO. �� CO'JST.
Do'r. Annlimni naCH•iECi rF�`� ��
NOTICE TO APPIICANT: I!, oqrtr making this Cr.rlifim'e of fNGi!�L NO
E.emption, you sheuld become sublect io �he Wo�kers' / ,(/� � VALOA710N
Compensn•�o�provisions ef ttie lohor Codr.,ycu must fcrth� n�C�55/�O� �sz,1 Z �,/�ei
wiih cemply wiih svch prevrsions er �his permil shall be iFL s / _�� VALIDATION �
dC�m��1 revC4ed. CGNTVACiO �� h0�<< <
LICE�SED CCNTRF�CTORS DECLARATION ��C.
�Aerr.6 aff�.m!hn�I orn licens�d wder nC^erc5 � P/ h,J�Sa�S'rJ '
y provisi�rs ef Chaota�9 "� `C
(commendr+g wlth SeUion 7000)ol Drvision 3 of ihA�usmess cii 1.11.e�ry..�,s C1n55 CS� S �r� �a L I; }
n�d Professions Code,nnd my Ii�c�Se is in(ull(o�cr.vn�efle;L C::�CR'PIipN CF lvd?K � �!� � • ^� �' �
Li;ens^Nu^�!+ r�� Li[.CI���� . n/ 'FINAL �� O
SV:IV.�•�NGPOO! ^La��/ DATE 3 'l�l�y ► � e •j j�� �
Conim<ic Dn!r. �nA U FINAI e n e � '"� � '� � �
SQ FT. ::(.i�; - lJ
w
� � 1 em evempt�nder Sr.c. S12E �� eY (;�.� ��-t5 J 4
N
B.RP.C.fcr this reasen ELECTRICAL � T
Dote: �,�, _
$iqnoture Steel 8 Conduit Bonding �_�_�_
Conduils,ConduCo.s,Eqoipme�� LCT
SINGIE FA:^IlY
H0.'E 0�'�tiFR�CUIICER CECLA.4ATION ?W!'.61NG -► "
1 hPrPhy o�fir •hm I am n�rmpt from�h�Contr�clor's LicenS=
Low(or il•.r. fcllow�nn rcason�Seciian 7031.5, Cus�ness and p_Tro � .,� �.7 f1
FI(:�C!<i(1^5 CCA^�: n �� • /'
GCS$y5'CT ' -
� I,oe owner of�he p.ope��y,w�ll do i4c plvmb�ng ond M�i�Syphon � ::e • ..e .J
eleCri�ol werk.I,or my cmplcycos wi�h wnges as iho�r
solr.compensation,or o Ilcensed mntreUor will do all f.".ECH�N:C�L � ° � G�::O�
ah=r wnrk nnd�6..s�rociwe is not in�endrd or offrreA � �-y/�
fcr salc(Sec!icn 70d4 BkP Cede). Swimming Pool Hr�icr 1�i • • I (`��!(1 u
CONSTRUQION LEND!NG 11GE�CY ,
I hereby o(firm thor iticrr.Is o cons!ruction lond;ng oqenty for ��,� �-�,�i�
ACMICANi
�h�n^�fo�mn�cr.of�he wo�k lcr whirh this pe�m��is issucd Fqi iFl.
ISe[.3C97.Civ.C.). I NT) �O. ►
lcad�r's Namc nODaF55
lender's AdAress P.C.fen S '3�' O � r'/ ��
Pnrmu Fne
1 cemfy ihnl I hove reod�his opplicolion nnd s!n�e ihm the
abo�e informai�on is cerrcU.I agree�o compiy with oll Caunty �p.�
nrd�nonces nnd Sln�e laws relatinq to building, electricnl, Isiunn<e Fee
mechonical�ed plvm6ing consk�ciion.and hereby outhorir� Mv-s•�qnnon frn /��• 'l �
rrprosrnlolivos nf rhis County to rtnter upon the above� To�d Fee V
menr"yn.ned P'ep�, 'ns ion purpeses. f (�
/ , ��r^/✓
�,5. i,.,>�ceS>i�«• c.n�.�i � Dn�e SEE REVERSE FOR F%PLANATORY LANGUAGE j�
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