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Home My WebLink About1490A 2173A 2174A (8)WORKERS' COMPENSATION DECLARATION I hereby affirm that i have a certificate of consent to self insure, or o certificate of Workers' Compensation Insurance, or a certified �ccoo�pyyt�thh�e,reof (Sec. 3800 Lob C. ) Policy No.TSL�Company- Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date "' Applicant CERTIFICATE OF EXEMPTION OV.M WO ERS' COMPENSATION INSURANCE (This section ri—d not It. completed if the perm.. is For one hundred dollars ($100) 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 Worker] Compensation Laws. Date J_�0_ L= Applicant I/L//r NOTICE TO APPLICANT: If, after mak' this Certi tate 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 and effect. License Number -!V-21 S��? Lic. ClaC S3 Contractor r0 "� /� �60 Ls Dote ElI am exempt under Sec. B.&P,C. for this reason SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I hereby affirm that to m exempt from the Contractor's License low for the following reason (Section 7031.5, Business and Professions Code): ID1, as owner of the property, will do the plumbing and electrical work. I, or my employees with wages as their sole compensation, or a licensed contractor will do all otherwork and the structure is not intended or offered for sale (Section 7044 B&P Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lenders Name Lender's Address I 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 tows relating to building, electrical, mechanical and plumbing construction, and hereby authorize representatives of this County to enter upon the above- mentioned properly for iins/s fiction purposes. , T—el/,� 9- //– f-% Signwure of Appl.—I or Agent Dore APPLICATION FOR COMBINATION SWIMMING POOL PERMIT ll 76A208 - CE876(318J) COUNTY OF, LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL INBUILDING ADDRESS g r. e. BUILDING ADDRESS /' LOCALITY CITY / p �, ZIP J NEAREST CROSS ST. O (L�/GOvI SIZE OF TRAC7 LOT t� LOT NO. V ASSESSOR MAP BOOK PAGE.. PARCEL OWNER T S d N TEL. NO. U ZONE ��' r{� �iNJ(f MAP. ' l/-3 Np, ADDRESS//pZEi /-4 O/'t0 SPECIAL CONDITIONS CITY — ZIP TJ 71 S DISTRICT !� G STATISTICAL CLASS CLASS NO. TYPE CONST. PROCESSED BY ARCHITECT OR - TEL. - ENGINEER NO. ADDRESS - VALUATION VAUDA TION " $ /L - .TENOL. CONTRACTOR .L .L-]� �L3/� Iv� s FINAL 0..A'E / 3✓ , - . 0 1 4 9 ysV R LIC. ADDRESS. -5[ `r. ,r 7 -5 P r NO. 3,5.6 %S CITY%/D LCUISY�;`-S - DESCRIPTION Of WOR SWIMMING POOL SPA - �(-/--TL-- - {i u • • • 2 1 SO. FT.' `� Y. SIZE 7 LI FINAL sY 1 -49.09 eco 4 Q 0 9 ELECTRICAL - - Steel & Conduit Bonding� - 09. 1 1-87 Conduits, Conductors, Equipment s'ej - - - PLUMBING ��SirG �j c 21 7 5 A Trop J Gos System- - ' SO t (.. XP.� � • • • 23 Anti -Syphon - /L -obft / ) ° • 2 1.04 MECHANICAL 49"FC 12Gn ow— • e 2 1, 0 4 i Swimming Pool Heater - Q Oy(/ C-s',(GA V • (��L D9.29-87 wcA��a✓r :2 2 1 7. 4 A APPLICANT TEL. (PRIM)&g L F N S NO. 2,2 . _ #i . • e • 3 ADDRESS a /` /T/ I • 17550 .. 1 7 5.5 0" G9.29-87 P.C. Fees O Permit Fee f (I`I) 7L All D 1 --eve. 10. S0 Investigolian Fee � Toral Fee 1-7 � s J - SEE REVERSE FOR EXPLANATORY LANGUAGE PLANS TO APPLICANT - - INSPECTOR'S NOTES To: Returned Approved No. - - Date "' No. Date STEEL & FORMS 17 LIGHT CONDUIT BONDING ..INSPECTION _. - - DATE - .. _. INSPECTORS- > LOCATION STEEL & FORMS 17 LIGHT CONDUIT BONDING CONDUIT GAS LINE WATER LINE SEWER �1 ANTFSYPHON VALVE - ELECTRIC WIRES FENCE (HEIGHT) /n �r�/77J-�/ ---------- -, GATES �SEISING tt F LATOCHING / ,D-' 7,D JIZ%17 01 ROUGH WIRING FINAL ELECTRIC - HEATER (LOCATION 8 VENT) GAS LINE TEST , POOL DRAINAGE P•7RAP 'OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License; Law for'tF.e following reason j(Soc )031.5) Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, -- or repair any structure, prior to its issuance, also re- quires -the applicant for such permit to file a signed state- ment that he is (icons ed pursuant to the provisions of the Contractors License tow (Chapter 9) (commencing with Section 7000) of Division 3.of the Business and Profes- sions Code) or that he is exempt therefrom and the bods for the. alleged .,exemption. Any violation of Section 7031.5 by any applicant for o permit subjects the apph. cant to a civil penafty of not more than five hundred dollars ($500).): - ❑ I, es owner of the property, or my employees with .... - :. -. wages cistheirsole compensation, will do the work, and 1ha(sfrudure 7s not infonded or offered forsa�e (So'c. 7044) -- - Business and Professions Code: The Contractor's License tow does not cpplyto an owner of property who builds or - - - - - - - Improves thereon, and who does such work himself or through his own employees, provided that such im- p, verrionts m- provements are not intended or offered far safe. If, however, Ire bullding or Improvement is sold within one year of completion, the owner -builder will have the _ - burden of proving that he did not build or Improve for the. -- purpose of sale). - ❑ 1, as owner,of Jhe property, em exclusively can- tracting with licensed contraciers to construct the project JSec, 7044) Business and Professlolts\Codc; The Contrac- - --- for's License. Law does not apply to an owner of property - ... who builds or Improves thereon, end who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law). ❑ 1 am exempt under Sec , B. 8 P.C. for this reason .,,Data Owner INSPECTOR'S NOTES