HomeMy WebLinkAbout1227A 1468A �' ,t ` t* ""�o" .� �^--`"`_
MPENSATION DECLARATION �
I hereby affirm thot I hove o certificate�of conseni io self ^
insure,or a certificate of Workers'�omPe�So��o���5�,o��e, APPLICATION FOR COMBINATION SWIMMING POOI P�RMIT ���
o errified ropy thereof(Se<.38 , ob.C.) �snzas � � ��
���0?5 /—a ��� cEws�a,ea, Il
volicy o. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN euuoiNc .
Certified copy is filed wifh�he coun�y bvilding inapec ADDRE55 �
tion departm . BUIIDING � �
ADDRfSS LDCAUTY �
Date � Applicanf NEAREST
[ERTIFICATE OF EXEMPTIO FR M WORKERS' CItY Z�P CRO55 ST. -�,
COMPENSATION IN 4NCE . TRACT�Z�� SIZE pF ASSESSOR
l0? LOT NO. MAP 800K PAGE PARCEt
(This ucf(on naad not bo complolod if�be parmif Is for ona TEL U5E ZOriE MAP -
O
hundred do0an(5100)or I�se.J OWNER " NO. NO. �� �
I certify�hof in 1he performanca of�he work for which Ihis � � SVECIAL �
permir is is5ued,I shall not employ ony person in any manner AD�RESS CONDITIONS
so as to become subjec��o ihe Workers'Compensatipn laws. DISTRICT S7ATISTICAI CLASS TYPE PROCESSED 8Y
CITV ZIP ' : CONST.
Date App�icant ARCHITECT OR 7E� �] �^1 CLA55 NO� `��' .�O�
ENGINEER O. / �J
NOTICE TO APPLICANT: If, pfrer making this Certificpte of �
Esemption, you should become subjecr to the Workers' qDDRESS vALUATfON �
Compensa�ion provisions of fhe Lo6ar Code,you�must forth- `r � O � VALIDATIOH
with comply with such pro�isions or this permit shall be CONTRaG70R �� s
� deemed revoked.
LICENSED CONTRACTORS�ECIARATION � �
AODRE
I hereby affirm that I om licensed under provisions of Chapter 9 ���, �j �
(commencing with Section 7000)af Division 3 of Ihe 6usiness CI7V CLA55
and Professions Code,ond my license is in foll force and effecL DESCRIPTION OF WORK �
fINAt � ►
License Number �� Lic.Class� SWIMMING POOL DATF ?
r'''''� A ('� / �� �2�(1
(�� � � �J( FINA4 /
Confraclorw�^'�h� Do��'���I��U S�FT. sr/'7��, � / _ #• • • o G'� O�:
� �am ezempt under$ec. SIZE � A�n . U
S-�. @ o.�.. " �
B.&P.C.far ihis reason ELECTRICAL ! % �4 � � dS
Date: - • . �./'f.�..;�x O
Si nature Steel 8 Condui�Bonding ��bq� U
g Conduils,Condvc�ors,Equipment �$,�C�'-�;�', Q
SINGLE FAMILY N
HOME OWNER-BUItDER DECIARATION PLUMBING � � , Z
I hereby affirm fhat I om exemp�from�he Contrador's Licensa
Law for the following reason(Senion 7031.5,Business and p-Trap
Professions Code): Gas System �
� I,as owner of the property,will do�he plumbing and Anti-Syphon G,��
electriml work.I,or my employees wilh woges ps iheir U
sole compensation,or a licensed coMractor will do all MECHANICAL �
othe�work ond the sfructure is not intended or offered ��
for sale(Sec�ion 7044 B8P Cade). Swimming Vool Hearer ��� Q�8 A
CONSTRUCTION LENDING AGENCY
1 hereby affirm thaf�here is a conslruction le�d�ng agency far �' � � � • • �
�he performonce of ihe work for which�his pe�mil is issoed AP��jry{ Np
(Sec.3097,Civ.C.). � � � � ° � 7 Jr,Jr(?
Lander's Name ADDRE55 • ���� " �
� /. ..,(iv
lender's Address f- p Q
P.C.Fee E .eO Permir Fee .]�(JU -�i' . O&-��
I cenify rhar I hove read this application and stote�hat rhe �t-�l �"-"� -�- --�-- . �' � ��,'
above informalion is correct I ogree to comply with oll County lesu ce Fea � � a �v �
ordinonces ond Stata laws relating �o building, electricol, °"
mechanicol and plumbing conslruction,and here6y oulhorize ���es+iga�ion Fee / ; t�-U
represenlolives af fhis Coun�y lo enter upon the abvve- To�ol Fee ''t!
men�io�ed property for inspecfion purposes. �� .
L
S� i e of Applimnf or Aganf oare SEE REVERSE FOR EXPtANATORY IANGUAGE
� PLAN YO APPtICANT j E. OWNER-BUILDEft 6gCLARATIGN
I hereby aRirm thoi I a xempt from'he Contractor's
To: . , . R�furn�d . . . License Law for�Ihe following reoson (Sec.�,7031.5)
Approved Business and Prafessions Code:Any city o uniy which
No. '- �ote No. 'Oata - � - � - . � - reqWres a permit to cans�rucL aller,improve,demolisb.
_ � or repalr ony sfrucfure, prior fo i�s issuance, also re
' - �� " -" � � ' • � quires Tbe applimn�for such perm�f to tile a signed state-
. . . . menf that he is licensed pursuan�to fhe provisions o1 the
� � � - � �� Contr6ctor's llrsrvse Law(Chapicr 4)(co mencing wifh
�- � � � - � �- SecNon 7000)�of Division 3 al fhe&usiness and Pro(es-
� sions Code}or fhat he is exempt therefrom and tbe basis
� � �� � � � �� �� . _ . for fhe olleqqel.exemplion. Any violofion of Secfian
INSPEC710N: DATE� . INSPECTOR - � 7037.5 by ony opplicant for a permir subjncts the appii�
. cont to o clvil penvlty of not more than five hundred
LOGTION � � - dollars($500).):
. � ❑I,as awner of the property,or my employees with
S7EEL f iORMS . wages ps iheir sole compensa!ion,will do ihe work,ond
LiGti'F CONCIiiT � - � ihe strudore is not inlended or offered for sale(Sec 7044.�
� � � � � � � 8usiness ond Professions CoAe:The Controcfor's Licensu
BONofNG� - � . - - � lawdoes no�cpply lo an.o��✓ner of prope,ty who 6uilds c�
. � �--� � � � � Irnproves fbc.raon,cnd who does such work himself or
� . . . 'through bis own employees, provided iha� such im
� - � � � provemenis are no1 infended or oflered for sale. Il,
� however,1he building or�mprovement i::sold w��hin one
tONDUIT � � � yeor ol completion, fhe o�iner-buildc-r wifl hove th<a
burden of proving ihat he d)d not build or irnprovo for fhe
GAS IINE � �' �� � purpose of sole), . , -�
❑.I,as owner of the property,am exdusively con-
WA7ER UNE � � trocting with I�censed co�ha<to�s to construct fhe project
($ec.7044)Business and Professions Code:�The Conirac-
SEWfR
� >ar's License Law does nof appfy to an owner ol property
. _ „ _ who 6uilds or improves thereon,pnd who tonirocts for
� uch projects with a mniractor(s)/icensed pursuaM�fo
� � fhe Contractor s License Low). � �
AM71•SYPNON VqLVE ❑I om exempf under Sec. ,B.&P.C.for this
' ELEtiRfC WIRES � reoson
FENCE(HEIGHT) . Do�e Owner �
Ga7E5 �SELF-G.OSING 1 � . ItrSPECTOR'S NOTES .
SEIF-IATCHWC� �
ROUGH WIRINC �S , � � �
FINAL ELECTRtC � � ---'—`--
XEATER(IOCATION 6 YENTJ ' �
GAS llliE TEST ��....�-�" - . . . . � —_—�—' .
POOI DRAINAGE �
P.TkAp � � - �