HomeMy WebLinkAbout1690A 2993A (10) _ _---
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f WbRR"ERS'COMPENSATION DEC�ARATION � �
� �"�,Y p`f`�m�h�,� have o`e�„`"°�e°``°�Se°'1°'e�` APPLICATION FOR COMBINATION SWIMMING PQQ� F�MIT
insure,or o certifi<ate o�Workers'Compensation Insuronce,
or o cerrified copy the�eof(Sec.38Q0, a6.C.J 7sa2os � � � ,
CE0]6(3!84) � •
Polky No. Company [OUNTY OF!OS ANGELES BUIIDING ANp$AFETI�
� Certified copy is hereby fumished. � �
FOR APPIICANT TO FILL IN euaowc �S
._.Certified copy is filed with Ihe county building inspec- ApD2f5S
tion department. BUiIDING �
Dpfe�Applicant AODRE55 ' (A'' �p�AI,ITY ,� - -
NEAREST , n �
CERTIFICATE OF EXEMPTI N F OM WORKERS' CITY . - ZIP CRO55 ST. � ri
COMPENSRTIO IN RANCE 3�7� S2E Of ASSESSOR
TRACT ! LOT LOi NO. , MAP BOOK PAGE PARGEL
(Thic�ufion ne�d no/b•compl�Md tf/b�p�rmN Is for on�
bundred do�4on(5100)er I�r�.) owNeR 3 � No usE�pN� �P �pdj�3 ��
I certif ihat in rhe rformance ot rhe work for which�his ��"
Y Pe G' / '7' /_ ._\ SPECIAL
permii is issued.I shall nol employ any person in any manne� /+D�RE55 `� � / -7 ( ��'n`� CONDITIOMS
so as to become subject to the Workers'Compensaiion Laws.� DISTRIC7 STaTISTICAL C1R55 TY NpGE55ED BY
GTY ZIP CONST,
Date Applimnl ARCHITEGTO n��'/� TE r' ^7 1U CL45SNO.�� n
ENGINEER J�+til(S' ��` NO. ! t T�� �
NOTICE TO APPLICANT: If, ofier making this Certificafe of �
Exemptian, you should become subject�to rhe Workers' AD�RESS � �7 �f/ , p `� � YA1t111T10N
Campensation provisions of the La6or Code,yoa must farlh- � YAUpMT10N
wifh comply with such PIOYI510l15 or rhis permit shpll be TE�� � ` � s �v '�C`+
deemed revoked. CONTRACiDR NO. .,)
LICENSED CONTRACTORS DECLARATION /' n� uC.
1 hereby affl.m rha�I om Ilcensed under provisions of thapter 9 ADDRE ,}�(,� �QCVL. �(WO. U S
(<ommencing wifh Seciion 7000}oi�ivision 3 of the Business . ���� -
and PwSess��ons Cod�and y licqqq(((���se is in foll force a d effect CITY � CtASS �
J` �o�� /� � �DESCR ION OF WORI( A � PINM
lkense Number � Lia Class\ . � SWIMMMG POOL pAiE . r-7 - �
co�o-o�ro. � Dafe�=��s.2,`� san ciN�t ' 1 6 9'G r, o
� sa.�r. \ er - „ a �. �� V
I am ezempt under Sec. S¢E L,) �
8.8P.C.for this reason EIECTRiCAI � � �� a 4�'�'n 9 U
Date: � , r�;� . �,s W
Steel&Conduil Bonding � � � ' '� � ���" d
Signalure Conduiis,Condu<tors,Equipmenr G��� � �—�)1 Z
SINGLE FAMILV _
HOME OWNER-BUILOER�ECLARATION PLUMBWG �
I hereby aftirm thot I om exempt from the Cantractor's License �
Law for rhe following reoson($edion 703I.5, Business and P T�oP
Professions CodeJ: Gas Syslem
� I,os owner of the property,wili do rhe plumbing ond AMi-Syphon - - �
e�eUriml work.I,or my employees wi�h wages as fheir .
sole compensation,or o licensed coNrador will do all MECHANICAL -
othe�work ond�he struct�re is not imendsd or oNared �
for sale(Sectian 7064 B8P Code�. Swimming Pool Heater `_��Q t�
CONSTRUCTION LENDMG AGENCY
I hereby affirm tho��here is o construdion lending agency for APp���N TE� � ,`-; o • e
the performance of the work for whicb rhls permir Is issued (pRWT ( � i ' Np,� � � ►
(Sec.3097,Civ.C.). /' / ( � + < '� %�
lender's Nome ADDRESS �,f �j I r -f ' C �l e �� }
Lender'S Address p.C.Fee§ �+ f.(V ��� / �� � r
�(/� Permit Fae
I certify that I hoae read�his application and stale Ihat ihe �s„U
above informotion is<orrecr.I ogree to comply with all Couniy /Q �
ordinonces ond Srere laws reloting �o building, ele<+riml, �ss� cePea ` !
mechanicol ond plum6ing mnslruction,ond hereby au�horize ���es���gouon Fee on (��r a - .
representa��ves of this County ro ente� upon the above- ia+al fee / J .
meniioned properry t spoction purposes. � ,
n
���.�� Z'�15�7 . "
S�gny �e of Applimnr o.Age�+ Dme SFE REVFRSE FOR FXVlANATORY LAN6UAG8
�.J
E �
� P{A1�9t'APPkI INE�. . .,ti �
i hereby affirm rhot I om exempt from�he Contraciar's
�O0 � ��F^� Licenre Low for rhe following reason (Sec. 7031.5)
Approv�d Business and Prolcssions Code:Any city or couNy which
'Jo. Oof¢ No. Oo1� � requires a permit to construcr.olter,improve,demolish,
. or reparr any s�ru<ture, prior to ifs issuance. o�so re�
qui es ihe opplicant lor such permif lo lile a slgned sta�e�
I � . menf tha�he is licensed pursoant fo thc prav'rsions of fhe
Centracfor's License Law(Chop�er 9)(<ommen<!ng wrfh
Secllon 7009J o�Divition 3 0�the 6usiness and Proles-
- � sions Code)or thet he is eaempf fnerel�om cnd the bosis
fw fhe allegad exemp�ion. Any violation of Seclion
INSt+fitilON DATE INSfECTOR � � 703L5 by any opplimn�(or a permit subjects the og�;.li-
oni fo a civif penofly o!not more fhon/ivc hundred
LOCA710N ' dollars(5500J.):
- ❑I,as owner of the proper!y,or my employees wiih
S1EEi B FORMS woges as thelr sole campensatian,will do the work,ond
LIGHT CONDUIT � � - . �he structure is not intended or offered 4or sale(Sec.70a41
� Business and Professions Code:7hc Confractor's Llrense
BONDMG . [aw does not cpply to an awner ol propertywha buifds or
� ' improves ihereon.and who doez e�ch work himself or
. � through his own employee:, provided �hot such im-
� provements are nm infended or oflered for sole. I(,
� . however,Ihe build�no or improvernenf is sold wifhln one
CONouii `z"� , yeor ol comple+iu�, ihe ownerbuilder wiU hove the
burden of proving ihat he did noi build or improve for the
CAS LINF purpose ol saleJ. �
� ❑I,os ewner of.the property,am exclwively con-
WATER L�NE �rocting w�th I�cen=e�con�rac�ors�o consirucf tha projeci
u�f� ;Sec.70aq1 Business and Professions Codc:The Contrac-
�ar's License.Law does no�opply�o an owner af prcperly
wha 6uifds or improves tAcreon,and who conkecis(or
� uch projeas with o coMrecion!s)licensed pursuanf to
. I . fhe Con7actor's Gicense Gew,l,
AN7I�SYPHON VALVE ❑I om exempl unde•Scc. ,B.8 P.C.40•th��s
ELEtTpiC WIRES �/ � redson _
FENCE(HE7GHT) � _�. Date Qwner
�SEtF•CLOStNO ` I ! ii"lSPECTOR'S KOTES
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