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Home My WebLink About0788 0789A .� �_ _ _ ' � t WORKERS'COMPENSATION DECLARATION � �� I hereby affirm rhar I have a certifimtP of mnsent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � insure,or o certifico�e of Workers'Com ensation Insurance, or a certified copy thereof(Sec.3800,Lab.C.) �snzoe . � l.z,� S�T�� CEB�6(3/84) ' � V� Policy No. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished � fOR APPLICANT TO FILL IN BUILDING � Ceriified copy is filed wilh the cou�ly 6uilding inspec- A�ORE55 Z tion depar�lyment. - ADDRESS Z 3�Z"" �� C ' LOCALI ' //.Q /��-� Date 4'�4 a�' Applicant NEAREST /j � CITY /L Z�P CRO55 5. vIM CERTIFICATE OF EXEMPTION FROM WORKERS' �.,/ SiZE OF ASSESSOR COMPENSATION INSURANCE TRACT I � ) tOT LOi NO. MAP BOOK PAGE PARCEL (This�action n�ad not be compl��d R�he permif i�for on� . TEL. Use ZONe MAP ^� hundred dollon(5100)or lass.) owNeR /� NO. .�.Ti9 �( �. ��n T 3 K' I certify thai in ihe performance of ihe work for which ihis � � SPECIAL permit is issued,I shpll not employ ony person in any manner ADDRESS CONDITIONS so as to become subjeU to 1he Workers'Compenwtion lpWs. � p D TRICT STATISTICAL CLASS TYPE PROCESSEO BY CITV � I� ZIP /I7 � CLASS NO. C� (/� � Date Applicant � ARCHITECTOR A^- �. � 7 � OL . NOTICE TO APPIICANT: If, afier making this Certificote of ENGINEER ��, qLy�/}1 7 Exemption, you should become su6iecl to fhe Workers' � YAWATION , Compensa�ion provisions of ihe Labor Code,you�must forfh- ADDRE55 � Attw�� ieL. / YALIDA710N with comply with wch provisions or fhis permit sholl be CONTRACTOR I�'�T/T�w7 N�, s deemed revoked. - UCENSED CONTRACTORS DECLARATION � ��' G F ADORE55 � NO. I hereby offirm that I am licensed under provisions of Chapler 9 ' � �� S � (mmmencing with Section 7000)of Division 3 of ihe Busineu ��n, � D��j�-f C�qr,� ��s� � ��'j,l and Prafessions Code,and my license is in full force and effetl. DESCRIPTION OF WORK �y��ff� /� (�`� fINAL � � Q license Number�1 "C.rV Lic Closs?_,L SWIMMING POOL � OATE ^'� �I'Q� a Conlra[for��"`^� Da�e ��I�� SPA FINAL L (� � ❑ 5�.FT. � SY l�I� ��! � I am exempt under Sec. SIZE � �� O B.&P.C.for lhis reason ELECTRICAL ��" n (�1j (,~,) Date: � /Y�-G�""dC O11�'� •�G'�'.. W Steel&Conduit Bonding � e�'�_ � $ignpture Conduits,Conductors,Eq�ipmenl '^��p/� Z SINGLE FAMILY �b � HOME OWNER-BUILDER DECLARATION PLUMBING I hereby affirm that I am exemp�from ihe Conhodor'S Litense �, �. .. * , y., � Law for Ihe following reoson(Section 7031.5, Bvsiness and P_T�pP � � '�7�.�'{� Professions Code): Gos S sfem ' � Y � I,os owner of the property,will do the plumbing and Anti-Syphon �+' ' ` `�'3 electriml work.I,or my employees with wogesas iheir sole compansation,or a licensed mnfraclar wiU do all MECHANICAI �� ° � ��'��J�i . other work and�he structure is not intended or oHered T�/ . ��_ for sale(Section 7044 B8P Cade).� Swimming Pool Heater ��J ° " � �� CONSTRUCTION LENDING AGENCY , �C,,�C)�E,+(� I hereby affirm ihal there is a mnstruction lending agency for APMICAN7 TEL � t6e performonce of the work for which ihis permit is issued (pRiNT) NO. � (Sec 3097,Civ.C.). � Lender's Name ADDRE55 . Lender's Address � p,C.Fae E ,V Parmir Fea 1b J r� I certi4y ihat I have read�his applimlion and slate ihat the . pq � abave informa�ion is<orrecl.I ogree to comply with oll CouMy � Isso ce Fee 1 yi� � ` ordinpnces and Stale lows relating ta building, eledrical, °" mechonicol and plumbing construc�ion,ond hereby authorize �nvestigation Fae . represema�ives of this Coonty lo enler upon the above- 7oial Fee �� ' menfioned prop rt f r�nspec�on purposerys. - Or�—Ot �q�awre I o o.�9e� Dare - � SEE REVERSE FOR EXPLANATORY LANGUAGE� � _� _- �,� ' PLANS TO APPLICANT INSPECTOR'S NOTES � OWNER-BUILDER DECLARATION Te R.}urn,d � I hereby affirm Ihat I om exert�pt,from the Caniracror's � � 'Licen'se•law ior }he followi7g�rahspr��(S�c. 7031.5) _, Approved Business and Pralesslons Code:Any tify or coun/y whlth No. Dote No. Paf� . - requires v permit lo tonstrutl,olter,improve.demolish. - . . , - . .. - . or tepoir any sVuclure, prior�o Its lssuance, also re� �,_��!,. -t� '-� � � ��qu,ires./Beopplicaniforsuchpermilto/ileosignedsiofe- . �� - ' . '��rr�nj thaf�h�i�licensed pursuont to fh'g proKis,lorys ol the Cb'ntrdcror's Llcense iow(Chapier 9)(tommencing with � - � - �� SecNon 7000)of Divlslon 3 of fbe Business ond Profes- - � sions Code)o�fhaf he Is exampt therelrom and�he basis � �. � . ��for 1he aUeged exemptlon. Any vlolafion of Section INSPECTION DATE ' INS��ECTOR. -,�"-� '`'� � 7031.5 by any applimn��or a permi�sub�ects�he oppli- y tonf fo a dvif penalry o�not more thon five hundred LOCAiION � t�,�� doflor3(5500).): � � �,�. y. � , � ❑I,as owner of ihe property;or my employees wiih STEF 8 FORMS � -. � � - � � , wages as their sole compenspfion,will do�he work,ond LIGHT CONDIIIi � � � .i�`,,.� � the structure is not intended or offered for sale�Sec.7044) - ' ' � -' Buslness ond Prolessions Code�The Controctor's Llcznse BON�ING � Law does noi opply fo an owner of property who builds o� '�� '� ' ' lmproves Thereon,and wbo does such work himsel/or � � -�� , ^.�;� � _�;� . , � !��: �hrough his own employees, provided �hat such im- . � �� provemen}s are not infended or ol/ered for sole. 1l, f.. � c,- _.t.�, ._ . , .\ .,,. however,fhe building or improvement is sold wHhin one CONDUI7 . /� � ` � � year of complefion, the ownervb�ilder wil! hove the - � - �� . �� • '_ � � burden o/proving ihat he did not bulld or improve fo�the GAS LINE a -.. _� .• � . purPose ol soleJ. . �� . . � I,as owner of the;property,yam exclusively con- WATER IINE � ' rracling with licensed mnrrac�ors to construct ihe projed � - � �{3ec.7Q44).Business ond Profe,ssi.png Code:�7he Conlrar SEWER - .,4� �- �or's License!aw does nol apply fo�an ownar of property �C � —�, - . who 6ullds or fmproves fhereon,and who con�rctts for � .such proJects wifh o ronirocfor(s)litensed pursuant lo . �be CoNratlor's License Law). ANT45YPHON VALVF � �I am eaempt under Sec. ,B.8 P.C.for lhis EIECTRIC WIRES reason FENCE(NEIGNiJ . Dale Owner GAiES ISEiF•CLOSINc � � INSPECTOR'S NOTES� � SSELF-IATCHING ROUGH WIRING - FINAL ELECTRIC /��,�,y'1 HEATER(LOCATION 8 VENT) ��Lr' GAS LINE TEST 2 � -- . POOL DRAINAGE � � P.TRAP . . . , . .. . � .,, . .. :.,` .