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Home My WebLink About1330A 5696A WORKfRS'COMPENSATION OECLARATION , • ` ~ T + � I hereby affirm ihat I hove a certificatP o+�o�sen�}o ge�f.. APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure,or o certifimte of Workers'Com ensation Insurance, � or o certi4ied copy ihereof(Sac.3800,Lab.C.) � 76n208 � . � TPI�SI�7B182T090�484 Travelers' ins�E-e�s�ivei� , o�cy o. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished. �. - - � � � FOR APPLICANT TO FILL IN BUILDING e� LL Certified wpy is filed with the caunty building in5pec ADORESS d.�5 T� tion departmenf. BUILDING Date1-25-84 Applicont Anthony Pools , Aooaess 21541 �mbushers Street �ocnurv arvDiamond Bar Z,P NEARE57 -�� CERTIfICATE OF EXEMPTION FROM WORKERS' � � E7 CRO55 57. COMPENSATION INSURANCE TRACT 33205 SIOZT OF 1O7 NO. S MAPSBpOK � PAGE PAR (Thi��action n�sd not ba completad if the p�rmit ls lor on• TEL. USE ZDNE MA7 hundroddollan(S10D)orlsts.f � OWNER Richard Malme ,vo.912-4144 �� n,o. � �q� 33 ' I certify tha�in ihe performance of the work for which this - SPECIAL � permit is iss�ed,I shall not employ ony person in any rnanner ADORESS 2� 4� Amb u s h e rs S t r e e t cOnlOiiiONS so as fo become subject lo the Workers'Compensation Laws. STRICT STATISTICAL CLA55 TYPE PROCESSED BY CITV ' ZIP CON57. Dote Applicant ARCHI7ECi OR 7F�, CLASS NO�` � _„,`^\�� NOTICE TO APPLICANT: If, after makin9 this Certifimte of ENGWEER $,J No. _ j� <<V�4, Exemption, you shoold become subjed to the Workers' VAWATION � Compensation provisions of the Labor Code,you�m�stforih- AooRe55 O bOX 22252-Commerce 9��22 with comply with such provisions or this permit shall 6e TEL 7�2 •T�5 . VALIDATION deemed revoked. CONTRACiOR �NO. _ � LICENSED CONTRACTORS DECLARATION � LIC. . ADDRESS O bOX 2225z No. 190179 � � I here6y affirm that I am licensed under provisions of Chapter 9 �� s � � �mmmencing with Sec�ian 7000)of Division 3 of the Business � y ondProfessions Code,ond my license is in full force and effed.� CI7Y CLASS _ a DESCR�PTION OF WORK license Number 19 017 9 �;�.e�oss C-5 3 swiMMiN�Poo� . ',, a FINAL . �� -�1 3 3 0 A u DATE`).� � � � 1-h�::. �. . . .2� oe conrra�ro�A�thony Poolsoa�a3-31-84 SPA FINAL ,u� O � 54.FT. py �.4 •5653 � I am exemp�under Sec. SIZE 550 � B.BP.C.for ihis reason S�1 ,y„ p�� •�6,5 3 u � EIECTRICAL � 'CO-+ Date: � e��c� 0.1.3 1 -8 4 � Steel 8 Conduit Bonding Signature � Conduits,Cooductors,Eq�ipment � SINGLE FAMILY �T� HOME OWNER-BUILDER DECtARATION PLUM8ING � � I hereby offirm ihoh I am exempt from Ihe Coniroctor's Litense Law tor fhe fallowing reason�Section 7D31.5, 8usiness and p_r�aP 5 6 9,6 A Professions Code): � < Gas System ❑ I,as owner of the property,will do Ihe plum6ing and Anti-Syphon � #�{ � � �3 electrica�work.I,or my employees with wages as iheir � , sole compensotion�or a licensed controctor will do all MECHANICAL � •2 O O.Jr C other work and�he shucture is not intanded or offered � for sale(Section 70a4 B8P Code). Swimmin9 Pool Hearer � . � � • •2 n�,5�_ CONSTRUCTION LENDING AGENCY . O 9,� 4—8 4 I hereby affirm lhat there is o construction lending agenty for ApP��GyM TEL. � the performan<e of the work for whith ihis permit is issued �PRINT) 015 Na�268-48 7 � (Sec 3097,Civ.C.). .Lende�'sName �a�h ADDRE55 b x 222 2-Commerce 90022 . Lender's Address p,�.Fee E 56. PermifFea� �L9O,�� I certify that I hove read this application and state that the _ obove informaiion is correci.I agree fo comply with oll County Issu ce Fee 1�.5� ordinonc ond Stat laws rela�ing to 6uilding electricol, � mecha ica and plu ing c nstruction,and hereby outhorize ��estigarion Fee � repre nt tive5 0 �(.� unry�to enter upon ihe above- 7otal Fee ZQQ.rjQ ' me o y f r i cti� es. � / nthon ools 1-25-84 . Signature of/+p�ant or Agen� �are SEE REYERSE FOR EXPIANATORY LANGUAGE -L.... - . .. . _ -- - PtAM1S 70 APPL C NT y INSPECTdR'S N E5 � OWNER-6UILDER DECLARATION •To: � qp��yd � I hareby afFirm tha�I am ezempt frorn th¢Contrxter'z License Law�for thc following re�son�`Sec. 7031.5) AppMved Ausiness and Professlons Ca�'e:Any cily w county wfiich P3c. -Daia Ne. Date requires a permif fo consfrucf,pNer,improve,demo!lsh, � .. . . or repair any structure,�prior fo ils Issuance, also re- � � � quires}he appllcanf(or sach permit fp 111e n signed s}p�e- - - : ment ihat he is l/tansedpu�suanl to Ihrprovis"rons ol the � � Contractor's License Law(C6apter 9)(commencing wiYh .. . $ection 7000J of�iWslon 3 of 11»B�Mdn�se o.:d Frofes- � - ' � � sions CodeJ or that he Is exempt therefrom and ihe 6asis ^- , . fa� ihe alfeged exempOon. Any vlafetion o/ Secflon . IttS�'°f710C�1'�" � I DATE INSPECTON � � - - 7031.i by any appliconf for a permi�subjects the oppli- ` � caM to a clvlJ penalfy of no}more fhon Nve hurvdred LOCATIOlt _ . I � - dolfors(�500).f: ----- ; - � ❑I,os owner of fhe property,m my ernployaes wifh �T�`-�E wRa15 � wages os their sole compenwtion,will do the work,ond Llf H7 CO�>;DUI7 � ry . the sfructure is not intended or offered for sale(Sec.70A4) `i� L` F - � ' Business and Professions Cade:The Con7octor's Lfcense ��h��,�G � � � - Low does nct apyfy ro an owner of propsrty who burlds o� � � � � improves ihereon, cnd who does sucb work himseN or � � � . � . � Ihrough his own employees, provided fbo/ such im- - � � provements are not intended or of4ered for sole. If, � . . however,the build�ng or Improvemen�is sofd wi�hln one� CONDUR I(°� �i.r year of�mmpletion, 1he owner-buifder wlA 6ove the burdcn o/proNng thq�he d)d nol bulldor lmprovo for IRe GP.S l!ri; � � � �, porpose of sale). , Q I,as owner of Ihe property,am exdusively mn- WI�YER LI?!f � � tradinq with licensed coMractors to consirvct ihe proje<t SEPlGR � � . (5=_c.7044)&rsiness and Prcfess-ion,s Code:iha Coi,tror �or's License Low does nol appfy�to an ownero(property . I . . � who bullds or improves thereorL artd who tontwcts/or such projects with o conrracfor(s)licensed pursuant fo . ' � � Ihe Confracfor�s[i[ense Lawl. ANTbSYPHON VALVE - � � � ❑1 am exempt under Sec ,B.&P.C.for�his EIECTRiC WtREo - � reo5on FEPJCE(H£IGHT) ✓ Da1e Owner GAT[S S�LF�QGSiNG } ' INSPE�LTOR�S FlOTES (SELFLATCHRIG J � ROUGH LYIRihf+ - . FIPoAL F1.EC7F.if � � HEATFiF(COCATIDPi&4ENT) GA3 LINE 7E5T !C / ' ] PCOL DRAIPoAGE ' . � � � P-TFAP I� r) f�' . .