HomeMy WebLinkAbout6690AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec.38 Lab. C.)
Policy No. Company
Certified copy is hereby furn shed.
Certified copy is filed with the county building inspec-
Datetion departm nt.
Applicant
CERTIFICATE OF EXEMPTIONRO WORKERS'
COMPENSATION INS CE
(This section need not be completed if the permit is for one
hundred dollars (;100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number : Lic. Class
Contractor`9�:� Date, -ILO "f� XY
I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, will do the plumbing and
electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical,
mechanical and plumbing construction, and hereby authorize
representatives of this, County to enter upon the above-
mentioned property for inspection purposes. s
76A20B APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
CE876 (3/84)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
_
BUILDING
ADDRESS
LOCALITY
j.
r J
NEAREST
CITY ZIP
CROSS ST.
TRACT c.
SIZE OF
LOT
o
LOT NO. J
ASSESSOR
MAP BOOK
PAGE
PARCEL
OWNER
TEL.
NO.
eUSEZONE6
MAP
N O. J
SPECIAL
ADDRES
CONDITIONS
DISTRICT
STATISTICAL CLASS
TYPE
PROCESSED BY
CITY ZIP
c)I
CLASS NO. f
CONST.
-
ARCHITECT ORTEL
ENGINEER
NO.
e
ADDRESS e��—A. s-
VAL ON
s
VALIDATION
TEL.
S
CONTRACTOR v� 4 y
No,`-*� e�
:
p
ADDRESS t" "` j NO. 9 r
LIC. ¢'"�`
CITY
CLASS `a
O' 2 1
DESCRIPTION OF WORK
SWIMMING POOL
_
FINAL
DATE(—
� e 4 2 1
( Lj 1,65
SPA
SQ. FT.
_
FINAL
BY
is 6 5
SIZE
fj
ELECTRICAL
Steel & Conduit Bonding
88
Conduits, Conductors, Equipment
PLUMBING
r
P -Trap
[ "I
Gas System
Anti -Syphon
MECHANICAL
Swimming Pool Heater
(. )
APPLICANT TEL.
(PRINT) �Vt,
NO.
ADDRESS
��
P.C. Fee $ (�+
Permit Fee
'
Issuance Fee
(�
Investigation Fee
� ��
Total Fee
�� C✓
Sig�ur of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE
To: Raf urned
No, Qofe No. Date
INSPECTION
LOCATION
STEEL & FORMS
LIGHT CONDUIT
BONDING
CONDUIT
GAS LINE
WATER LINE
SEWER
ANTI-SyPFI$A VALVE'
ELECTRIC WIRES
FENCE (HEIGHT)
GATES (SELF -LATCHING SELF -LATCHING
ROUGH WIRING
FINAL ELECTRIC
HEATER (LOCATION & VENT)
GAS LINE TEST
POOL DRAINAGE
P- 4 RAP
I!�lS�E �R' NOTES OWNER -BUILDER DEC;LARAIiON
- I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Sec. 7031.5)
Approved Business 0nd Professions Code: Any city or county which
requires a permit to construct, alter, improve, dernolish,
or repair ony structure, prior: to its -issuance, olsar re -
vires the applicant for such permit to file a signed state-
menf that he is !tc€nsed pursuant to the provisions of the
(toil tractor's'License Low (Chapter 9) (commencing with
i Section 7000) of Division 3,of .the Business and Profes
cions Code) or that he is exempt therefrom and the brash,
for .the alleged exemption. Any viviution of. Section
;TR t
7031.5 by any applicant fora permit subjects the appl'-
cant.to a civil penalty of. not more than five hundred
J dollars ($500):):
n. 0 I; as owner of the property, or my employees with
--
wages as their sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 7044)
Business and Professions Code: T -e ontroctor's License
Low does not apply to an owner of property who builds or
- improves thereon, and who does such work himself ar
through his own employees, provided that- such Im-
proveriier,fs r r
_._ are not intended ooffered fosale. If.
M hovvever, the buitdiny or improvement is sold wiffrin one
year of completion, the owner-buiider will have the
burden of proving that he did not build or improve to,- the
purpose of sale).
0 ,1, as owner of the property, urn exclusively con-
- Iraciing ,,ith licensed contractors to construct the project
(Sec 7044) Business grid Professions Code: The Contrac-
"' for's License. Law does not apply to an owner of property
f — who builds or improves thereon, and who -contracts for
_ such projects with o contractor(s) licensed pursuant to
the Contractor's License Low).
i✓ j . y , �.� �". D 1 am e.xeiiipi under Sec.—__.____ B. & P.C. for thi,
reason_____._.._.
Dole ____Owner
INSPECTOR'S NOTES ._