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HomeMy WebLinkAbout1050 S GRAND (3) WORKERS'COMPENSATION DECLARATION APPLICATION FOR COMBINATION SWIM� � � / I hereby affirm ihof I have a�e,,,f��ofe o+�o�5e���o se�f MING POOL PERMIT � insure,or o ce�tificme of Workers'Compensa�ion Insurance, � or o certified topy thereof(Sec.3800,1a6.C.) . . 76A2oe . .- . . . . . . � CE.875(lt/BI) , �Policy No. Compony ' � COUNTY OF LOS ANGELES BUILDING AND SAFETY � Cerfified copy is hereby furnished.. � ' � � fOR APPLICANT TO FILL IN euimuac G7. O Ce�tiiied copy is filed wirh the county building inspeo- ADDRE55 �� �D,.�V . ,tion depafiment. , . �.c ��. BUROING �(� �t � p �/� 2 �-1F"•''� /I� o/. � A�ORE55 {— CJ• y /J L�+•S�� LOCALITY.. �•YC/. •L� �Dafe �`��7���Applicanl r �`' � � NEAREST � � � - -CERTIFICATE OF EXEMPTION FROM WORKERS' ��tY � ����� Z�P CR055 57. � COMPENSATION INSURANCE � SizE OF a55E55oR � 7RACf LO7 LOT NO. MAPBOOK - PAGE PARGEL (Thi�s�ctlon nMd nm be compld�d ti th�pvmli ti for on� y lEL g � ZONE MAP, hundnd dollan(5100)or Ins.} � � OwNER /�pN� i S3�/t NO. !��"7yr NO. 1� ����. I cert�fy tha�in the perlormance of the work Por which this y7 [/ -y— � SVECinL permil is issved,1 shall nof employ any person in any monner ADDRESS � � V /7•�G-!7 S! • � � � CONDIT�ONS � � � -5o as t0 beCome Subjecf to Ihe Wofkers'COmpenSOfion Ltlws � - � � DISTRICT STATISTICA�CLASS NPE . PROCESSED BY � CITY ,'^f'7oT � 21P ...z�'�b CONST. Date Appliwnf ARCHITECT OR � TEL � 0 �+SS NO. - �NOTICE TO APPLICANT: If, after making this Certiiitate of ENGWEER NO. / ��, Exemption, you should 6ecome subjact fo Ihe Workers' �- - � � VALUA710N ' � Compensoiion provisions of Ihe Labor Code,you must forlh- /DDRE55 . � �� � VpLIDATION with comply w�h such provisions or Ihis Permit shall be TEI. _ - � -- � � deemed revoked.� CONTRACiOR� � craK..[.-� �NO.L�=7� . . UCENSED CONTRACTORS DECLARATION / ���' . ADDRE55 < � D�� o rf ILS:n]� NO.I��IC Z �I hereby offi�m thai I am licensed under provisions of Chopter9 LiC. _ - (commencing wilh Section 7000)of Oivision 3 of Ihe Business.- UTY �� �•��-� � ��55 c—S 3� � � � �- and Professions Code,and my license is in tvll force and effecr. oeSCxivTiON OF WaeK � � � F�NAL � 'Li[ense N�mbe� LiC.CIo55 SWIMMING FOOL � DATF ► �8 6 5.5 A a ��.tG�.r�-i 3—(3 b`� SPA '!7!<� "'_'�� � FINAL #e • • •`Z� � Contmcfo Date SO.FT. By U ❑ SRE W I am exempt under Sec. 50 �'� •3 L.22 N - B.BP.C.for this reason � ELECTRICAI - .. ' � � � . • • �J�.2 L c�5 Z ��e: B - ' 0'a 1 2-85 � Si nature Steel&Conduit Bonding , � - , 9 Conduits,Conductors,Equipmenf � - � GL FAMIIY ' - � HOM OWNER-BUILDER DECLARATION � PLUMBING � � � - I heieby affirm that I om exempt from Ihe Contraclor's License � � �S b�J.�J{� � Law(or�he/ollowing reason(Secfion 7031.5,8usiness and � �� - � ���� _ � Professions Code): P-Trop � . � #� � � � � ' - Gas Syslem . .. ._.. _. _ � .. . � � I,as owner of the property,will do 1he plombing and � ANi-Syphon � , - I • 1 2 5,5 0 elecirical work.I,or my employees wilh wages as Iheir . � sale compensatioqor a licensed contraclor will do all MECHANICA� � � � - � � e = - other work ond the strucWre is not intended or offered � - � , �v 5�� � � � -for sale Section 7044 88P Code. � - - - � � � �^� � ( ) - Swimming Pool Hea�er � � �7j,� C-fj 5 CONSTRUCTION LENDING AGENCY -� � � '. � � I hereby offirm thol fhere is a conslrudion lending pgency for ApP���NT TEL � '� � �he performance of the work for.which this permit is issued _ (pRINT). . NO. � I' ' ..(Sec.3097;Civ.C.). - � � . _ �-.a� . Lender's Nome ADDRE55 - �� � � . , . . ,ly�� .. . Lender's Address p.C.Fee S � -� -��S �7 ���-- -- � � � I certify ihof I have read this opplicalion and slate ihat the •^2� ve.mitFne '�f'„ above informafion is correcf.I agree to comply with all Coonty. Issuonce Fec � �'.Sv� - d�s � � ordinontes and Stofe lows reloting fo building, eiectrical, � � � mec ical and plumbing mns�roc�ion,ond hereby authorize Invn�igo��on fea ` � � ,�F�;•� " - �re res �o�ives of Ihis Counly�to eNer upon the above- Toiol Fea ��� .sU �,� m nti ed r ert for i ettion porposes. � �� � -- � � � . � ,�—�3-��`� �F �5ig �mre of Applicanr or Agen� Do�e � � SEE REVERSE FOR EXPLANATORY IANGUAGE � ' ` ��. � �% � � ` � 5� PLANS TO APPLICAN7 � ' ' INSPECTOR'S NOTES - OWNER=BUILDER DECL4RATION ' - � To: . Fefumed . ��. " - . ' _ � � - �� � , I hereby affirm�hat I am exempt from Ifie CoNratbr's • Licensc Low far fhc .fallowing reoson (Sec. 7031.5} I � "�Approvod � � � �_ , � Buslness and Prolesslons Code:Any city or counly whicb No.- ._ . Dctc� No. � D6ta. . .._ - _ .._ .... _.._'._.. _.. . .. .. . � � roquires a permit fo consfrucL olter,Improve,demo6sh, . . . . �\ ,i. . . . . -_ .._.. ..__. . _.. , . _.. . . . .._..__ _ .. .- or repalr any structure, prior lo Ils Issuonce, olso fe- � ' � � ' ' qvires Ihe applican�for sucb permll fo lile o slgned sfale- . , �, _� �'. .� . �_ _. ... ...- -..__.. . . ... _ ._ ._ . _ .. .__. �� . - � . . . � . � . . . �>..mcnk thal Fe is liccnsed pursuonf la Ihe prov)slans of fhc � . � � � � � �Contrattor's C7cense Law(Chap�er 9)(commeirNng wilh .- - � � - � , � SeUlon�7000J ol Dlvlzlan 3 0�fFo Busfness and Profes- � � � � s(ons Code)or fhol ho ls oxempf iherefrom and the basis _ �;; � . lor 1he alleged exempllon. Any vlolotlon.o/Secfion ' ' - � ' ...� .. . , .� " . � .ilJSP.CTION----� 'DATE- �— �-INSPECTOR . ,. • • ��,. ... . ` . ...••'�'�.`��' � . 7031.5 6y any applicanl�for a permi�subjecls fhv oppli- �� - - - . � cont to c�clvi)penolry of not'more ffian five hundred � . w[aTION.. ...._. .... .._ 1 �. :" . . . . . .`, . '. ...:.. _.._ '. 't,,,..1 , , ._ . doflars(5500).J: , . . . ,.� . � �� " . �.. � ��� .�� �❑I,as�owncr af the properfy,or my employees wiih STEEL 8 FORM1IS � h���� '.�_ . . . �.�� . . �ypges a;iheir sole mmpensalion,will do the work,ond LIGHT CONDUIT ' '� ' - . � ihe slruUura is nof intended or offerod for eale�Sec.7044) � �•�-� �-���` � �-� -- � �--���-���-� �-- � ---�� �- � - �- �� ---� ' � '-0uslness and Professlons Code:iFe CoMroctar's Licanse E04DING ' � Lawdoes not apply lo an owner of property who bu(Ids br '��'��'^�� ' � - �- ---.� �"� -��- �� "�- � - -�-� �- -- Improves fhcrcon,and who does suth work h(msell or � � � � � ' 'ihrough h1f own employces, provlded thaf such Im- ' � ��������� � � �� � � � �'� -���� � - ���� provemenls are not infended.or oiicred for salc. If, ' � -, . � ,� , , . howcvea fhe 6Wlding or improvemenf Is sold wi�hln one � � CON�UIT . � � • �, � � year ol complerton, Ific owncr-bulldnr wlll hove �be y � _ . . - .. . _ .. __ - - _ � � ..bvrdenolpravingfhathedidnotbWldorlmprovelorfbe ' GASLINE �," t '�s, �•:.. ,-. . � � • -�-: ' pvrposeofsale). . . , �. . �: - � . - ❑ h I ' I . . �..� :. -� -- , I,as owner of f e properfy,am exc usrva y mn- ' WATER LIN: f '_ �� ,_. �..__ � . ; � ' ,' . iractinc�wilh licensed coMradors to consfruct ihe project � � . � �. ,. ., . . . __ � _ .. �C.(Src�17044)Qvsiness andProfesslons�Codvr,�JheConfroc-. SfIY:R . foPs Llcensc Law does nol apply to bn owner of properfy � � ' ' i,. _. .'�� �•.^��: . __ . - _ . _ . __. _._. . . . - who bWlds or lmprovcs thcreon,and who canlrath/or , � � such projects wHh a confroctor(s)Ikensed pursuaN fo -� -thc Controc}or's�llcensc law). � ANTI-SYPHOH VALVE � � . ... .-.� . . .., . � , _ , , . , . ❑Iamexcmptundoi.Sec:_�.8.8P.C.forthis EIECTRIC WIRES reason FEhCC(HFIGHT) . ' - � ' Oate � Owner GATES rSELFCLOSING � - � � ' - INSPECTOR'S NOTES � • '��SELF-LATCHING � i1 .. ..,. .. . , � .. . . .. ROUCH VlIRING' ' � � . ' � FIPIAL ELECTR�C , . . - - . . ' . . ... .. .. . . +, , .. .. . ' , . . . , . . . ,. , __.. ... .. _ . _. . . . . . . ,_... .. .......�...., .. ._. . . ...... .._ _......_ . _.� HFATER(IOCATION 8 VENT) ' � GAS LIN`.-TEST �l: .� .. . ....,- . .' . . _.. . .'. . ., . � . . . POOL Q�AI�7AGE N'' : -. . � . � .' . . .. . P-TRAP � ' _ . . . . .. . .. , � � � ' ...:'.;'.:_...._... : ..-�.:'..-....'... . . ... ....... . ...., ' � � �.I _. . '� .. :'.\.. _ . ... . , .. ,..,... .. .. . . . . �, l. \ � •