HomeMy WebLinkAbout1393A 1598Aw WORKERS' COMPENSATION DECLARATION
Lyereby affirm that I have a certificate of consent to self
insure, or o certificate of Workers' Compensation Insurance,
or a certifiedcopythereof (Sec. 3800 Lab
C. )
Policy No.22' py� TCompanyl vt,r. -Q 4-ti"1:14
Certified copy is hereby furnished.
Certified copy is filed with the count building inspec-
tiicon department. .�
Date ! ?Appi con,' —
CERTIFICATE OF EXEMPTION FROM WORKERS'_
COMPENSATION INSURANCE
(This section need not be completed if The permif is for one
hundred dollars (SIDU) 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/1and1,efffect,.
License Number `LL"I r"1'. 'I el. Lic., Clgss �'v �Z
lam-• L --' 7
Date
1 am exempt under Sec. .
B:BP.C. for this reason
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
e lectriml 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 inlended or offered,.
for sale (Section 7044 B90 Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending aency for
the performance of the work for which this. permit gis issued
(Sec 3097, Ci, C.).
Lender's Name
Lender's Address .
1 certify that I 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,
echonical and plumbing construction, and hereby authorize
representatives of this County to enter upon the above-
n�perly far inspection purposes.
Signature of Applicontor Agent Dare
APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
78A200
CE876 (3l841
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING 1�^
ADDRESS G...
BUILDING
ADDRESS
,
LOCALITY .
CIN IP-
NEARE
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ASSESSOR
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NO.
SPECIAL
CONDITIONS
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STATISTICAL CLASS
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DESCRIPTION OF WORK
SWIMMING POOL
SPA
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DATE !
,
FINA`-!).,n.si+Jf
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i ¢ ®� Y. 9SIZE
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J.isl-E,i (7C, `& ZS FG i�i
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ELECTRICAL
Steel 8 Conduit Bonding
Conduits, Conductors, Equipment
sVbL
PLUMBING
Trap
's ; C, a
Gas System
_
Anti -Syphon
MECHANICAL
Swimming Pool Heater
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1 -87
APPLICANT TEL.
(PRINT)
NO.
ADDRESS
P.C. Fee $
Permit Fee
1 IL'S r V V
aanc
Iss a Fee to,
Investigation fee
/f r+
S of
Total Fee
j .; •
SEE REVERSE FOR EXPLANATORY LANGUAGE,
INSPECTIONI. DATE i INSPECTO
I LOCATION
STEEL -.FORMS i
UGHT CONDUIT
BONGING
I
I
CONDUIT
i fJ GJI
GAS LINE
'If
72,1/7V
WATER LINE
i—
1
SEWER
y
FI
�Kzz
_
1
AMTISYPHON VALVE
i
ELECTRIC WIRES
FENCE (I [EIGHT)
U
GATES /SEL'r-CLOSING
`SEIpF/[A7�CHfING/
i z 17.E AJ
yy,...�.�
ESE
1 ROUGH WIRING
I,L}•. i
FINAL ELECTRIC
HEATER (LOC=TION VENT)
CAS LINE TEST
i POOL DRAINAGE
P TRAP
ON/NER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors
,f
License Law ?gr .the, fo{lowing reason,;(Sec. 7031.5)
Business and Professions Code: Any city or county which
requires a permit toconstruct alter, improve, demolish,
'Ur -repair any structure, prior to its issuance, also -r
quires the applicant for such permit to file a signed state-
r - - -
ment that he is licensed pursuant to the provisions of the
- °
Contractor's License. Law (Chapter 9) (commencing with
Section 7000) of Division 3 of the Business and Profes-
sions Code) or that he is exempt therefrom and the basis
-
for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applr-
_
cant to a civil penalty of not more than five hundred
dollars. ($500).,:
- . 4» i
❑ 1, 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: The Contractor's License
•
Low does not opply to on owner of property who builds or
improves thereon, and who does such work himself or
`
through his own employees, provided that such im-
provements are not intended or offered for sale. If,
-7.` . -
- however, the building or improvement is sold within one
-
year of complefion, the owner -builder will have the
.- ... -
burden of proving that he did not build or improve for the
purpgse of sale)
. G I, as owr,e/.-fit�eproperry,'aln exclusively con-
tracting wl'F IlcZfised contractors to construct the project
(S._, 7044) 8- ness and Professions Coder The Cantrac-
-
tors L cons - to,, does not apply to an owner of property
who builds or improves thereon, and who contracts for
/ such projects with a wntracforrs) licensed pursuant to
! the Contras or's License Law)
❑ 1 am. exempt ender Sec.--. B. & P.C, for this
�easan
Date— Owner
INSPECTOR'S NOTES