HomeMy WebLinkAbout1441A 1871A ._.----- -- --- - ---- — - -- . __ . .: --.- - ,
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WDRKERS'COMPENSATION DECLARATION �
I hereby affirm Ihol I hove a cer�ificole of�o�5e���0 5e�f qpp��CATION FOR tOMBINATION SWIMMING POOL PERMIT
insure,or a cert�fica�e of<Norkers'Compensation Insurance,
or o certified capy�hefo4($ec.3800,L .C.} � 76n20s - � - �� � � - � � �
�, CEel6(3lB41
Polks'y r7o.�'�Compony COUNTY OF LOS ANGELES � BUILDING AND SAFETY
� Cer�ified copy is hereby f�rnished.
FOR APPUCANT TO FILI IN BUILDING
Certified copy is filed with Ihe tounty 6uilding inspec• �� � ADDRESS .ZS
�tiOn()epar�meny BUILOING ' /�
Date��v—�� AD�RESS- ' LOCALI7Y '� �-_'J�
Applicant f NEAREST
� CERTIFICATE OF EXEMPTION O WORKERS' CITY �'V�QKc{ ZIP CROSS 57.
" COMPENSATION INSUR CE a�ao IZE OF ASSESSOR
TRACT OT LOT NO._ MAPBppK PAGE PAR�EI
(This s�cfion n�vd not b�complof�d�(fM p�rmit Is for on� q 7EL. USE NE MAP f
{�undhd dollors(SI00)or bss.) � OWNER /L NO. — �/ � NO. � / �
I cerlify Ihat in the performance of Ihe work for which this C ^ SPECiA�
permit is issued,I shall not employ any pe�son in any monner ADDRE55 �J ( GS QaV CON�ITIONS
so as to 6ecome subject to the Workers'COmPen501iOn LOw3. DISTRICT $TATISTICAI C1A55 TYGE PROCESSED BY
� CITY � IP ' CONST.
Do�e ApplicoN ARCHITECf OR I TEL. /�� QASS NO.�2
�NOTICE TO APPLICANT: If, oNer making this Certificale of ENGINEER ' l�2(,{ NO. 'QO"� `�J
Eaempfion, yau should 6ecome subjecf to the Workers' � VALUATION
Compensation provisions of Ihe Lobor Code,you musl forlh• ADDRESS
wiih comply th such provisions or this permi� sholl be � TEL. s VALIDATION
deemed revoked. CONTRA�TpR � INO. —��� /
LICENSED CONTRACTORS DECLARATION � \ /� UC.
A�ORESS � J�p7��t �NO. � � �
I hereby offirm thot I am licensed under provisions of Chopter 9 ��� f � -� . -
(commencing with Seuion 7000)of Division 3 oi the Business - ��TY - Cau � �� 4(;�� A
and Professions Code,and my license is in full force ond effect. pESCRIPTiON OF WORK
�` Li[.CIa55�� SWIMMINGPOOL . � FINAL . . , •
License Number - r'•�• •2�
� DATE ,0.-%-`�'T--��. a
Controctor `��1��� Dale �� SPA FINIIL/�' -- � � ° •4 9.0 9 U
� SO.FT. +� � .6Y �!��! . � e e./�.0 G O=
I am exempt under Sec. 'iZE � � Q.'
6.8G.C.for this reoson ELECTRICAL � - . . .- .. � � �� �7•� E`�8 5 V
Date: � � ��� a
Sleel 8 Conduil Bonding
Signolure Conduits,Conduc�ors,Equipmenf Z
SINGLE FAMILY . . - . . . � .
HOME OWNER-BUILDER DECLARATION PLUMBING �� � '�
I hereby affirm Ihat I am exempt from the ControUor i License . . , , �� ��7 ' �
. Law for the following reason(Secfion 7031.5, Business and � ��
Professions CodeJ: P-Trop � .
- Gas System � . �
� I,os owner oi the property,will do the plumbing and Anli-Syphon �� S 7.� A
electrical work.I,or my empioyees wi�h wages as lheir
saie compensation,or a licensed contracfor will do oll MECHANICAL �• • • � i 3
olher work and 7he structure is not intended or oHered - � -
for sale($ection 7044 B8P Code). Swimming Pool Heoter � �� • � 7.�d Jr�
CONSTRUCTION LENDING AGENCY �- - • '.�7 S 5 O�
I hereby a�firm fhat there is a construttion lend�ng ogency(or AP���N TEI. p �
Ihe performonce of the work(or which this permit is issued.. (pRINT O. /)/'= a , 0'7�2 9�8 Jr
(Sec.3097,Civ.C.J.
Lender's Name ADDRESS � - . _
lender's Address p.G Fee S •-V Permil Fee / �P���� �
I cerlify tho�1 hove read this application end slate Ihol the '� '
abo�e iniormaGon is correci.I agree to comply wifh all County hs� re Fea ��<`S� ' -
ord�nances and State laws relaring ro bu�lding, electrical, �
mechaniml and plumhing mnslroclion,aad here6y nuthorize ��+esi�gonon Fee . , j�� [�� ,
representalives of Ihis County to enter upon the above- Toiol Fee � J �
- meNioned propeny far im eUion purpoaes. _ _
�-1 Y���'-
S�g ai� of qppLmni or ngenr po+e SEE REVERSE FOR E7IPLANATORY LANGl1AGE � ��
vtANS 70 APPLICANT ' - � - tNSPEROR'S NOTES� � OWNER-BUILDER DECIARATION .
, To: ReTumed I hereby affirm Ihat I a n_eiem�!from the Controctor i
��Approvod Licensc Law. for the following reason'(Sec. 7031.5)
� �Boslness ond Pro/essions Code:Any clly or counly which
No. Oofo " No. - Dato � . '. .... . . ...- . . _ . . -' �
reqvires o permil lo tonsfruct,alter,improve,demolish,
.. , ._ _. . _ or repalr any sfrucfure, prlor fo lfs Issuance, olso�re�
� - � ' qutresfheopplicaN/arsuchperm7ftofileaslgnedsfafe-
- - � - - . . . . _.. i _ , , � � � menl Thaf he ls Jiconsed pursvanf�o�ho provizions ol/fie
� • � Confrocfor's L�cense Law(Chapfer 9)(rommen[Ing wlfh
- - - . - � -- - - - - -� � � � - - - Secflon 7000)of Divls(on 3 oi 1hv Business and Pro/es-
' slons Code)o�}haf he!t exempf lherelrom and the basls
-- - � � � ��� for fhe olleged exemptfon. Any vlolatlon of Secflon
INSPECTION OATE" � INSPECTOR.. : �� " ' ' 7031.5 6y any applicaN for a permit sub(ects Ihe opp0�
� cont fo a clNl penolty of nof more 1Fon five hundred
tOCAiIUN i ��� � � � � � �� dollars(5500).): i ,
, J�� . �I,as owner of Ihe propeny,or my employees wifh
STEEL E FOFMS ^ _,�__� � � . � wages as their sole compensation,will do the work,ond
' ISGHi CONOUI7 �� ���'� � � �� � � � .the strucfure is not intended or offered for sale(Sec.7044)
... .. _ . _, .. . � .
Bustness ond Professions Code:7he Conlraclor i Llcense
60NOMG , �'l�J ' �� ' . - . s �Low does nof apply fo an owner ol property who bullds or
� - � - � -Improves ihereon,and who does suth work himself or
� � � . � , � � _ . fhrough hts own employees, provided fhaf�svch Im-
� - provemenls ore nof inlended ar ollered (or sale. 11,
. � however,fhe butlding or Improvemenf Is sold wifh(n one
C-,. ' , � � � � � - ' yeor of mmpletion. fhc owner-bullder will hove Ihe
CO�DUIT � ����y" �( �.J . ��6urdenofprovingtfiothedldno�bvildorlmprovelorlhe
GAS LWE ��1 ��� J � �� purpose ol sale). � '- . . . ,
' - , .. . � '❑'1,as owner of Ihe properly,am exclusively com
. VlATER tINE ti.� � ��� - � Irocting wi:h licensed controcton b mnsfrucf ihe projeU
. , 1(Sec.704A)Business ond Prolessions Code:7he Confrac
SEWER ' � "" - - � '�for's Licenselaw does nof apply to on owner olproperty
�� ` �__ / _ _ _. ._, who buflds or improves themon,ond who tonfracls!or
. '�� such projects w�th o ronfrocfor(sJ licensod pu�svanf to
�1hc Contrarfor's License LawJ. '
. ANTI�SYPHON VALVE � `�� i� �. " , ❑I am exempt under Sec. ,B.&P.C.for this
. ELECiRIC W12E2 � , . . . . . reason � . . . �
FENCE(HEIGH7) " Dotc Owner
GATES SEIFCLO:ING . , . .
(SELFdATCHING� � INSPECTOR'SNOTES
n '
ROUGFI WIRING � � .. . , . .
�
FINAI EtECTRIC . �vW'~ �'�--J 1.
' MEATER�LOCO.TI0�18VFNT) �pr�a '��-�
GAS LINE TEST I.,��.�.,-"- _ - .' ' __' . . . ' ' . .. , .
PODL DRAINAGE . . � '
P.TRAP _. , ,