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HomeMy WebLinkAbout1819A 1820A (10) i5'COMPENSATION DECLARATION - � -p��tia�e a ceriificare�of consent to self APPLtCAT10N FOR-COMBINATION SWIMMING POOL PERMIT imfe of VJo�kers'Com nsotion Insuiance, � ry fhereof(Sec.3800,lah.C.) � pe�2os � � � � - �� �� � �� � - ' - � CE878(9!Ba) •� Company� �`���`� COUNTY OF LOS ANGELES BUILDING AND SAFETY �py is hare6y furnished. �.topy is filed wi/h ihe counly building InSpee- FOR APPUCANT TO FIIL IN �DDRESS �S�! �e � � �37 �,artment. .. BU�LDING r/rfi ADDRE55 D �a IOCAUTY �� ..�ApPlicant � NEAREST •^ERTIFICATE Of EXEMPTION FROM WORKERS' . ��TY � Lv . CRO55 St. COMPENSATION INSURANCE TRAn 3Jl'�j �OT�F LOi IsO. � MAP BOOK PAGE VARCEI . ��i�cNon nMd not be compbf�d if fh�pwrmit I�fer oe� iel. USe 20NE Mnc' . `L - . ,dr.d dollen(S10o)or I•s..� owr�R .lC�'t�'� NO.t4l!'�'.7�3 NO. T' 3'� ��ertify fha��in the performonce of the work for which this � S���A� �� permi�is issued,I sholl nof employ any person in a�y ma�ner AOORE55 CONDITIONS so as to become subjed lo�he Workers'Compensation laws.. � � DISTRICT STAnSiKni tta5s irve VrsOCE55Eo Br . . CITV ZIP QASS NO CON57. Dote ApplimM RRCHIiEQO /�� � -�TE�� �� NOTICE i0 APPUCANT: If, after making this Certifimte�of ENGMEER j��G[-c 7 No .�la•Q��/ �b � -E�emption, you sfiovld become subject fo the Wo�keri �- " �� Vl1lOAlqN Compensation provisions of 1he Labor Code,yov must forth• Ap�RESS �/OZ7..r /�/�/�� . . VqUDAT10N i1h comply wilh such provisions or Ihis permil shall be � � TE�' S �2—�`�\./ deemedrevoked. ' � CONT8ACT0 �N���J 3 LICENSE�CONTRACTORS DECLARATION � ` /'_ ���' ADDRESS cJ3a �C�Y/A-o N0.3SUISTJ � f �'S .1 hereby offirm thot I om licensed under provisions of Chaptar 9 � ���, ' - � , .(commencing wiih Sect�on 7000)o(D�vision 3 af�he Business �� - � � nqSS ��-3 �-. _ _ �L�,yo , � ond Professions Code,and my license is in fvll force ond eHect. DESCRiv7iON OF wORK 7 � �S7I'�S'LJ -C�� � FIN����/ ►. :.`.�� ��.C/A � �license Nu er Lic.C�ass SWIMMING POOI L^fd DATE l . a Gj��`��p-/ $PA' �J FINA �r n e •'o'Z� O Contmcror Date�J�/1 Y �,FT. . . . . . � _��� V . ❑ _ er � 0 .5281 � I om exempt under Sac. SIZE B.&P.G.for this reoson � ELECTRICAL � �. "� �� � ��4'S�.�1 � O Oole: g .�y� ��. � 'n.,n 9"Pi 6 � Steel 8 Condoi�Bondin � p" Signorure Conduiis,Conductors,Equipmen� � � � � - � ' - . z . . SINGLE FAMILY � . . . . - - . .. - ' �L/r . - — HOME OWNER-BUILDER DECIARATION PLUMBING -► 0 b� - 1 hereby affirm thot I am ezempt from the ConlraUo�'s licanse � .. . . . .. . . . . . � law for the followin9 reoson(Section 7031.5,Business and p_T�aP �� , � � �� �2�Fl Prafessions Code): � � .Gos Sys�em . . . � . _ - � I,ns owner of 1he property,will do ihe plumbing and Anli•Syphcn efadricai work.I,or my employees wi�h wages oa�hair , _ �,�c o r e e j sole compensation,or a licensed contractor will do oll MECHANICAL - ' � • � �j�.Q Q olher work and Ihe structore ie not intended ar offered � � � - ' . - � �' � � � for sole(Section 7044 B8P Code). Swimming Pool Heater � ., � - ....4•�, `'� . �^ � ��'.Q�c=-� CONSTRUCTION IENDING AGENCY� � � . � - . � I hereby offirm thot there is a cons+ruction lend�ng agency for qpp�ICANT . 7E1. � � �'��9`8 6 the performonce of ihe work for which Yhis permif is issued (pRWT) NO. , �Set.3097,C�v,C.). � ' � '"- - Lender's Nome ADORE55 ' ' ' ' - -�- - � - � Lender's�Address �-� � ,�7�� � . - P.G Fee E SZ��I Fermii Fce ���'� `� I cerNfy�hai I hove reod this applimrion ond s�ate that ihe , r � ,. •• ` . . . obove informalion is corre<L I a9ree lo comply wilh all Counry� - � -'� " -" is�va�nce Fea ��� `S� ' � ordinonces ond S�ate laws reloteng to build�ng. elec�ricnl, �meer � Fee � ' --� � � mechoniml ond plumbing cons7ruction,and here6y avthorize 9piO" -. . . 8�'('J � �epresentotives of ihis CouNy �o enter upan rhe obove- Toml Fee menli ied prope�y ec on purposes. �. . _ . . .. . .._ . . . i�, � � poie , ���SEE REVERSE FOR E%PLANA70RY LANGUAGE '�� P[ANS TO APPIICANT � INSPECiOR'S NOTES '� OWNER-BUILDER�DECLAR, To: Refom�d � . .. . , , I hereby offirm 1ho��om exemp�fror A rov�d Licensa Law for iho.foliowing reasc _ PP _ , . _ __ ,,_ . , ,_,_. . ... .. Bu:lness and Professions Code:Any cl�y No. --Doto� � No. �afe � . .. � requires a permif to consfrucf,alter,Imp, . .. . .---.. . . . _. . ' oi repvlr ony s�rucfurc,prlor 10 Its lss� � •" �- ' - ' qoires fhe oppliconf for such permif fo(ile c - - - - . ._ . . _. . . . Tnenl�lhofheisfitensedpursuanifofheprov. Controc�or's Liconse Law(Chapfer 9J(iommE - - - , Sectfon 7000)oi Divlston 3 of Ifie Business an. � � � � ' � � ��•� sfons Gode)er Ihvf he Is exempf fherefrom and ih. � , ,for the alleged exempfion. Any vlolofion o! S. INSPECTION � : .DATE" 1NSPEC70R � - � � 7D3L5 6y any oppllcanf(or o pe�mt�subjvtfs fho o� canf fo o clvil penoNy of nof more fhon tive hundr. LOCATION .. .. . - 'flollars($500).): '. .. , • ❑f;as owner of ihe properfy,or my employees wi�h 57EEL 8 FORMS . ' � � woges as their sole compensation,will do the work,o�d ❑GHT CONOUR � . . , � - � � , . - -tha strotture is nm in�ended or offered for sale(Sec 704A) , - - � -�- Buslness ond Professlons Code:ihe Conlrattor's llcense BONDWG ' � . .- . - � � - � , � Lawdoesnolopplyfoartownerofproperfywho6uildso� � --- � - � � -- �- � �'� fmproves Ihereon.and wFo does such work hlmseff or � /--/"`-'--�- • � , _, -. Ihrough hls own employees, pro�7ded thaf sucb im- � , - � � " - - provemen6 ore nof ln�ended or o(lered lor'"safe, f/, ��. .. . howeveq Ihe bu11ding or Improvemen�fs sald wl�hln one CONnuti '�• �yeor of'completion, ihe owner-6utlder wil!have �he ��^�� � � _ . . . . � . . . burden of provtng fhof he did nof bu7fdor Improve tor Ihe GAS IINE ' ' ' ' � � p�rpose of sole). - , „ � , ❑1,as owner of Ihe.properly,:am exclusivoly con- � WATEe qNE � __ �_ ., . � � 1rotling with Ircensed contradors�o conslroci ihe project � {Se2.�70�e)Business ond Prolessions Cade:The Contrac- � 5£WFR ' �- �-,�;�. - ��"t��or i Llcense Low does nol opply fo an owner o!property . . . . , . .. _. . . . . � _ . . who 6utids or fmproves ihereon,ond who contracfs for �such proJeds wrlh o tonfroctor(s)licensed pursuonf�o _ 'the Cvntrodor's LRe�se Low). - ANTI-SYPHON VAIVE . . ❑I am exempt under Sec. ,B.&P.C.for this EIFLTRlC WIItES � rcasan � FENCE(HFIGNT) � Date Owner 4qTE5 �SELF-CLOSING � -� - . INSPECTOR'S NOTES - SELFdATCXING ROUGhI WIRING , 0�., i ._ � . . . FINALEIECTRIC 'jf'> �Lr—�-- . _ ... . . _ _.._..-. , , , . , HEATER(LOCATION 8 VEN1I . .�... . .. � . _...- . _ . . GASIINETE57. �p ---. .. � - ' . . � '. " . , , . �� .. POOL�RAINAGE . _ ' _ .. . __'_ _ . . . , , � P-TRAP . . , , ., . \��_ `, �