Loading...
HomeMy WebLinkAbout1673A 1474A (10) -- ; n�� _ -- -- ,- . — —. ---- ___ ,v r � � V/ . .��� WORKERS'COMPENSATION DECLARATION �b`� � ' J � �J�(� , I hereby affirm tho�I h"�e a ceriificate of�0�5=�<<a Se�f -.APPLICATION FOR COMBINATION SWI�MR�P�QIl��T �Q� insore.or o certificate of'rYorkers'Compensation Insurance, �� �-- or a certified copy thcreof jSec.3800 .C.) ��ealoe � �- � � � - �� - � � CEB�6�31841 Polity No.�Compg�y - . . . . COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereMy furnished. � FOR APPLICANT TO Flll IN eunov.ic Cerlified copy is filed with the count 6uildin inspec• AODRE55 tion dapartme L � BUILDING /�� AODRE55 / LOCALITY - Da�e Appli�on NEAREST CERTIFICAiE OF EXEMPTION FROM WORKERS' ��tY ZIF Cv055 57. COMPENSATION INSURANCE - � . TRA�7 b Si2E OP ASSESSOR LOT l07 NO. MAP 800K PqGE . PARCkt (Thi��oclion n�rd nof b�compl�Nd if 1F�p��mif fs for on� TEI. � U (�J E � Mo.a I1Yndred Aollor�(S��O�or I�ss.J ' � pWNER NO. �-I" NO,� �(�-+ �� � I cerlify Iha�in the periormance of the wo�k 1or which fhis ' SPECiAt �� permil is issued,I sholl not employ any person in onq manner AD�RESS CONDITIONS ' so as ta become subjeU lo ihe Workers'Compensation laws. DISialCi STATISTICAL C1A55 TYPE O BY � � CITY ZIP � CQr15T. Da1e Applicant � ARCHITER OR TE� CV.55 NO. � �/ NOTICE TO A7pUCANT: IF, oftermoking this Certilimte o( ENGINEER NO � Q Exempfion, you should become subjett�lo the Workers' � J VAIUAflON Compensa�ion provisions of fhe lobor Code,you must fonh- pODRf55 t �� /� . . . VAIIDATION wilh comply w'th svch provisians or this permit sholl 6e � - -- TE�� j deemed revoked. COMRACTOR. �NO. UCENSED CONTRACTORS DECLARATION � - � liC. ADDRE55 , � NO. � ' I here6y aiffrm Ihal I om licensed under provisions oi Choptar9 ��� f . � ' � (commencing wi�h Section 7000)of Division 3 of fhe Busines� Ci7Y � CLA55 � and Pro(essions Code,and my license is in full lorce and effecL pESCRIPTIOtd OF WOR ,--.�/ � /'�'�j �(1 fINAI � � license Number./�VC-c� Lic.Clos� SyyiMN,ING POOL L(�—J D�� �(p(�i LJ � •'1 L 1.3 A� a Contracror �� �Q1�, �are� SPA FINAL � , � o�� 0 sq.rT. n, �'` '2 1 U sr � I am ezempt vnder Sec. SiZE I�L�L� ' ° ' , ,�•�'�,. Q B.BP.C.(or this reoson ELECTRICAI - - � - � -- � � � ' �� {- Date: � . . ` ` •% �.��'��U. . Si naWre . . Sleel 8 Condoif Bonding. . .��/. .�„�' G�.' C'_�� � 9 Conduits,Conduaors,Equipment � z � - SINGLE FAMILY � - � - - . . . � HOME OWNER-BUILDER DECLARATION PlUM81NG � -' � � � I here6y offirm tho�I am ezempl irom Ihe Controctar's License . . � �, � Law for�he following reason(Saction�031.5, 9usiness ond p-Trop � P�'�j,-kN Professions Code�: � Gas System - � � N��o . . . � � I,as awner of the propery,will do ihe plumbing and Ami-Syphon U y� l - .electriml work.I,or rriy.employaes with woges as thair � . .� ��` �� .�t� � :_� `;�,G.F. sale compensation,or a licensed controctor will do all MECNANICAL �.l V other work and the strucNre is not infended or offered . . � " � � � � � ��y O 5� ��+Ior sole(SeUion 7044 B8P CodeJ. Swimming Pool Hea�er , - CONSiRUCTION LENDING AGENCY �� � - ° c_J C'.c�;U' I hereby offirm tho�7here is a construUion lend��g agency for �j . Ihe pe�lormance o1 fhe work(or which this permif is issued AvapRINT) N0��7�� ��'�'� �—E? (Sec.3047,Civ.C.). � . � . Lender's Name ADDRESS � - - � � . - �. Lender's Address p.G Fea S � V Cerm�r Fee O + U I cerufy thot I hove reod this applicotion ond s�ale�hoi the /� obove informo�ion is correU.I agree to mmply with all Counly � Issu ce Fee �O' `� ordinances ond Staie lows relating to building, electricai, °" . � mechonical and plumbing mnstruction,ond hereby awhorize invesiigar�on Fee. . . ���-„C� �� - � res nt 'ves of Ihis Coanly to enter upon Ihe o6ove- Tmoi Fea J io property r inspeclian pu�posas�� . . . _ . . . . ._ . . � SignaNre of Applicont or AgeN Do�e , � SEE REVERSE FOR E%PLANATORY LANGUAGE { L.r e [ c�s _ - . . .: � � � - - .��� �� .. ' L A I[ ..,. '� . . � lNSPECTOR'S N07E5 . ' � �. �� ... .. " ,. . - . �OWNER BUILDER DECLARATION To: Rofumed -I hereby aff�m that I am ezemp`?rom the Contractor's � - � License-low for the foliowing reason�(Set. 7031.5) �Approvod - Duslness and Pro�esstons Code:Any ci�y or munty which No. - ' Date �� No. - �afo _. . . _. .. .. .. . __. , _.... _.._ _ ......._. , . requtres a permif to conzlrucl.o(ter,tmprove.demolish. - �� • � -�or repalr ony sfrucfure,pNor fo its l:suance, aiso re� � ..,- � _ . _.__:.. .. _ .. . ._.. .. . . ..' '_.. ,. . . � - - " - �� � quires 1he appficonf!or such perm��fo Itle a slgned s�ole- . , . . ,. _ . .. . . .-. -- . . . . . - ment IBat he Is licensedpursuanl to the provisions of fhe � � —Con}ractori Llcense�Law(Chopfer 9)(commencing wifh ' ���-- - � � , � - . - - --� �-- - --�� � -- � . � Secllon 7000)of Division 3 oI�ho Bus�ness ond Pro(es- �� ' � � ' ' • sions Code)or fhot he Is exempf}herelrom and�he bosis , � � � � --- � � - . � � - , . 1or.�he.ofleged,exemptlon. Any violotfon oi Secfion INSPECTION --DATE�' � INSPEROR' � � � � 7031.5 by any applitanf!or a permif,sub�ecfs fho oppli� - - . cant to a clvfl penalry of not more ihon f�ve hundred loCArloN � � . �- � dollars(5500).):, - .. . .. � ❑I,as owner af the propery,or my employees with . STEEL 8 FORM;. � �� "� � wages as Iheir sole compensalion,wiil do ihe work,ond �!GH7<OAouR ; .' � . , , . � � ' ' . _.fhe strudure is not inlended or offered for sole(Sec.7044) ' � � Business ond Prolesslons Code:Tho Confracfor's Llcense . .. . ' _... .... . _. . . . ' BONOING ' �- � � - � ,, . - - , . . .Law does nof apply/o an owner o7properfy who�uitds or � � � ' - -- - � �-- - �mproves./Rereon,and who does such work himseli or . � .� ' 'Ihrough hfs�own�ompfoyees, provided that socti im- - � - - � - - �-- provemenls are not infended or of(errd for sale. !f, � � � . bowever,fhe 6ulld�ng or improvemenl is sofd wNhin one COKDtlIT .n�{L ��'� 2�( � � ' �yeor of tomplelion, 7Be ownerbuilder will have }he hurden ol pravfng ihot he dld no�huild ar improve for fhe GA$LINE��IL iD S$ C�/ pGfpOSC Of Sole). '� ' ' �� � ❑1,as owner of Ihe,properly,om enclusively con- wATER lWE - � � � . -"�"iroc�ing wiih I�censed coMroctors`ro construct the projec� SEWEe � . � , . . _ . (Sec.J044)8usiness and Professions Code:7he Confroc- � � � � -- ror's Licensc Law does nol apply fo an owner o�property � , , ,., . . _ , , . who bWlds or Improves ihereon,ond who con�racis ior urh projects with o�mntractor(:)licensed pursvonf to � � � . . --�he Confracror's License CawJ. � ' ANTI-SYPMON VALVE '.�/�;, : �� - ❑I am exempt under Sec. ,B.8 P.C.for this � _ . . ..__... _ .._._ ... ._ .. _... . ., ELEC7RIC WIRES reasOn FENCE(IIEIGHT) ��Zp . �ote � Owner }� � eAies �SELFCLD`.ING � . _ � - � ��� � � WSPECTOR'S NOTES SELFLA7CHING LY.X'->C �-t�J f7L�n"� , _ . , . . - ROIIGH WIR!NG .. , , . . .� . ' FINAL ELECTRIC HEATEF(IOCATION$VENT) ... . . ..-.� ._.�...... ...... . .. .... ...... .. ' ' . . . . . . . ..._ . CAS LiNE TEST .. . . .— ' �-'-._ � .. - -- . . . � . POOL ORAINAGE � - ' , � .. .. . . P�RAP ' . . . ., , , . .