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HomeMy WebLinkAbout0882A 1487A (4) WORKERS'COMPENSATION DECLARATION � � I . I hereby alfirm thaf I hove o certificote of�o�=e�<<o Se�f . APPLICATION FOR-COMBINATION SWIMMING POOL PERMIT - � insvre,or a cert'Fitare of�W�rkers'Com ensotion Insura� ceaia i3/ea� � . or a cerli'ed topy Ihereof�Sec.3800,Lab.C.) � 76a208 � � - - � - �. . . . - . � Poltcy�--Compon COUNTY OF LOS ANGELES, BUILDING AND SAFETY � Cer�fied copy is hereb furnished. � � � � FOR APPLICANT Tp FILL IN BUIIDING Certitied copy is filed wilh the unt vi i inspeo AooRESS - /V� lion deParlmanl. BUILDING . .. • . �a�����PPlica � ' � ADDRESS� C�-� IOCALITY-- ., � .�. .. ' J�_�� NEAREST I M 1 N FROM WORKERS' CttY - iIP. .... . GRO55 Si.� �. . COl F TIO SURANCE � � ��M1(,�S"lty SRE OF nS5E550R : � . TRACT .! LOT LOT NO. . MAP BOpK � � VAGF� PARCEI_ (This uNfon nNd nof b�tomp �d if 1M pvmlt Is(or on� ♦ TEL � USE ZONE � � MAP.. ___.. �. . _.. .. .. ._ bundnd dollnn(SI00)or I�a.) - , - � OW rt p�p. � . .. . p�p. . . . . I certiiy dim in rhe per/ormance of the work for which�his � ' . ... . _ � SPECIAI � .- � ... . . . ...... .. . permit is issued,I sholl not employ any person in ony manner ADDRE55 CONDITIONS '� so os ro become sublecr to ihe Workeri Compensotion laws. � �. Di57eKi SIATISTIGI QA55�� TYPE � pRpCES$(D BY- � . CITY ZIP � ; CONST. . � Dote A liConf ' � ARCHITER (� � TEI -�SS�."-'�: . � NOTICE TO APPUCANT Plf, ofter making this Cer�ificate of ENGINEER l� N ' �S � �� � � � '. Exemp�ion, you should become subjeU to the Wwkeri � �� � � � � � � � �� V�U�DON � � � �� ��� �� . . � Compensarion prov'�sions oi�he Lo6or Code,you-must fonh- AODttESS with comply with such provisionz or ihis permit shall be� � � TEL _ - � , � � �VALIDATION � - deemed revoked. � CONien OR - �- � . . .. � .. :. .._ . _ . _. . . .. UCFNSED CONTRACTORS DECLARATION � � �-- ���� r' � � I hereby oH'�rm�ha�I am licensed undar prpvisions of Chop�er 9 ADDRE . - s , ��. s3.���y�- . _ _ __. . . (commencing wi�h Section 7000J of Drvision 3 of the Business- �� Cu ��� l.-�"' � � ' � ( -�� � and Professions Cod ond my license is in fulllorce and eHed. � � �"� '� - �-� - � ��- � ��- � �ESCRIPTION OF WOR fINAL - � License Num�� lit.Clas�_ SWIMMING POOL - � � o�rF �: j ►, �0 8 8 2 A � .I n I '!�q SPA . ... _..._.. ._ .._ . . . . FINAL Contr r � �e - — � � . .. � • • •2 3 .. a , ❑ -— so.Fr. _ er I am exempt vnder$ec. , � s�zE �. _ ���� i :2�7 2 8'S� � , .., . . . B.BP.C.forihisreason . . . ELECiRICAL. . . . . .. ._. . ' ''. . _ . ...._. . '�_.I._... ' �...• ., _.,_ oaie: • �27285o O . _ . . . __. F- � - -Sleel 8 Canduit Banding - '� - � �B,� 5-8 8 �. U Signoture Conduits,Conductors,EquipmeN � �- �-- � I � - ���-- W SINGtE FAMIIY � .. .. . . _. . ... . .. .. . .�' � ' . . N HOME OWNER-Bl11lDER DECLARATIpN pWMBING � � � � � � �� -� � ���� ��- - � � � , z I hereby affirm that I om axempt from Ihe ContraUoi s License . . .. .. ... . . � � ; — � law for the follawing reason(Saction 7031.5,Businass and p-Trop " � � - � � � � � ProfessionsCode):� � ,. . . . . GasSystem �� . . . � _. . . .:.. _. �;. : .. . . � �... '. .'�. � I,os owner of the property,will do tha plumbing and AnfiSyphon �� �. . � electrical work.I,or my employees wirh woges os their . _. . ._ _ . . .�� � -�-�-��-� -�� ---� .i ..... ._,.... _ , . _ ,.., ... ... . .... _. sole compensation,or o licensed contrador will do oll MECHANICAL . � ofher work and 1he strucNre is not intended or afferod ��� -.. - . , � .... . . ._ . .�� Q a 7(� �for sale(Section 704d BSP Code). � Swimming Pool Heoler � ��--" � �.• , .� CONSTRUCTION LENpING AGENCY � � � � .� I hereby affirm Ihat fhere is a conskoction lending agenty for APPLICANT iEL. .�� . .. . .- ..... �'i .. . .. �:.�. � •�6 5 2 5 0 Ihe perfarmnnce of 7he work for wh'ch�his permit is issued. (pRWT) . . _ . �_ ... p�p, (Sec.3697,Civ.C.). . . .. . .. �,� .. _ Lender's Name ... . .. ..._ . . . .. .. ,�.�. .o �6 J�2,Jr' a e:� ADDRESS � � � � � � ' � Lender"5 Address p.�.Fee S v�1,5��� Pe�mir Fee � Ul�(�O\.n� .. . . "..... . .... . . . . _ 8& . 09.D9- I cerlify 1ha1 I hove read�his applicotian pnd 51a1e thol the ��;,� i - � � � obove informotion is mrrect.I agree ro romply wi�h all Counfy Issu ce Fee� ��.�11 �' ordinances and Sta�e lows relating �o building, elec7Ncol, ' °^ � , � �' ��� mechonical and plumbing construcnon,and hereby outhorize �^�e:rga*o�iee _ . ��+� �'� �- �'�- -� � �� -���� : � - � � - represen�a�ives of Ihis C o enter upon �he a6ove- � - iowl Fee J �`1�� 1 �' meNi ed ro iy for' spec�ion urposes ��� �- � -� � ' - " � � �-� � 5 ot e pp�mnr or ngen� � � SEE REVERSE FOR FXVLANATOYY IANGUAGE - � �� I . i�_ _ .._ ;, _.. _+. . . ... .... ...,... .. : � .. ,. ,,,.. ,��..,. ;. . , ,. .._ .. . >,. , , ��PLANS TO APPLICANT�•�� �- � -° � '�• � � • INSPFCTOICS NOTES��' � • � � � ��� OWNER-BUIIDER�DECLARATION .. ...,.: : ,� .. .,. . � I hereby offlJ^ih i I om e empt f o Ihe Gonlrocl6r's '�� To: . .T _�Raturnod �� . .. .. :-�. ' " . . •- '.:..1 a��.••^...�..,., /lllicepse La (forl t�e foltowng'roo q����(Se�;-,7031 5) �- ��A�P�aY•d � • -Business�a d Professio Codc."Any cHy couniy which Nd�-" "`Oote -'No1 .-'rDcf i ��:`r- -" � ._. .."""'"' .'.:..'.. ... _""_`. .'._...".. requlres ap rm t fo conshuci.aMer.tmprove.demolisb. . �.. - .�._ti..-..:- :_�.,i� .:_.�,i- 1 -.�:-�`" �.__. ____.. _ �./ -_ .- __i `�or'repb:r any'structoreapnor la lts issuante also�re� �, ;� ' � r �{.-.. .. � �; _.,..'1�� , :(-�_,f; ;..' :� �.. �.... �`: quiresfheoppl�mnrlo 3�chporro�i�eflleo:igned:ro'�c� �_ ._._�__._ ..._. _-_ ��._..�_ ._. _:.-_.� ..��_.:i_� � � 1. . .. � menffhatheislicensedpursvanll- Ifup�oJistons�olthe ��.:. ' � '_'.. ' -: � _ � t �- ...� ... � , ''.;� � t �.- ' ----Coniraclor'silcense'law�(Chcpter4)(�o`mr�icnana�wlrh -..-- !- �Y '�- � ---. �---... .. ; ..- -'-� -�- ,- --- ' '.-. :.. � Settlon 7000)of Division.3,of�ffio s str,cis aod pro�os� , .....i .. I ��' ~ 3 ` �� � ��� slons Code)or fhaf he ls exempf therclrorri ond fhe basls i_._ _ ,_------_. . . __. .._�- _ ---..,... --'.z. �'_.��._._. _._.. ,--- ._. ( .. . .. . - . ,,,-1pr.the.:alleged pezemplton.,Any.vio(aHon�ol 5ecno� ��_INSPECTION __-DATE_-_-. JNSPEROR - �� �` �"'t���. t; � � � 7031.5 by any opplicaM.�Ior.o perm�f�sub�ocfs�he cppti� � � �-� � � ,..��,canf:fo o clvll ponalfy,ol not more Ihan Jive Aundrod tOCAt10N- --!_..'rr--------- -.--- '.'!.. _ 1 .- �.�� , �dollars(5500).):. , . � .. . ,.. .:. __.. _ . , -�. , _ . ,.�.. _.. . ; � � � '� � . ..��•n.����I,�❑ ownerof.lheproperly,ormyemploy eswilh STEEL L FORMS � � ' ' � � " - . ..'. n. ,- i 1. .__.______. _._._ .._.._,.__._ ,...__._.._ _... ._` wa9es as fheir sole mmpensation,will do the work,and tIGHi CONOUtT�%�� �� . � } •���--• ` ' ..--�he.slruct�re Is not intended ocoffered for sole(Sec.JOaa} »_._. ._...,,._.__, . /. .....,_._ J .�...�_._..�..__. _.._.._.I t �_i_�- ; ..;���._..'�t�}�i•'>.1�...)/r� � '�' �.�._.� �' + 4• ..Bus�nessandPro�esslonsCode:ThoCon7ocfor'sUcense BOMOWG � - � ' �"- �"�"�''� , , -��'>�lawdoesnotapplyfoanovmer.o(proherfywho6ulldsor � ' ---- --- ---�� -- �-- Improves dhereon:�-and who.docs'suc work himseff or ' � ._ ) �� .,1-S _ _ t-�.. ,f.,1 �• � �(hraugh`hfs�own-employeies,'provided fhof-such�Im� i . ":_J . � "- ��" , --� -"i provemenls o e nof nl nded o ofle ed°lor'eale.-�l(. j � �.. .._i t � . _ ,�1 �,�.r.'� �C :: )� _l-. ho ever.ihe 6vilding `ro.e �i Is sald uhln anc CONDuti ����' � � Q�, �� - �� � �. ' . p effo�, Ihe-o heNb"ifder wlfl hove Yfie . ����- � yc r oF�c f , ,_ ,. �_�._ _ �.,� , ,�� � � _ .,6urderi olproving fhaf he d!d nof bu fdor lmprave for Ihe GASIINE - � J;.� ' `" ` purPOsc.ofsafe)... . . .: � .,�-' . .... WATER tINE ' � " �� �� ,, :�� - .._��..����as owner of tl e pfoperly o�n exclusively con- .' _ .. .. . .���..: � . . . _ .... . _ . . . ._..__'.. �.._.___ __. �-'., f f aUin9 w ih 1 c- ed c nr cto s i nstrud the project SEWER ' - '"�.�- �� ""'�� -�' � i S ��(Se����044)-B sines;vnd.Professio sfade�T6eCon�roc- . ? ' ��, '� � -� - (', !, ,'�•, �-.�.';. -�1�-for's 4lrensc Low daei nof dpply to on ov.�er of properfy � . (� �,i,... ,. . _ . _._.__... ___. ..___.__�, .;.t_.'.�,,._�.._ who builds or Improves thcreon,ond.who tontroctsYor ...----�-- --- --. .-_ .. _ .. --- - � � �� � ' � - � such projecls wifh o conlraUor(s)licensed pursuont lo t ... - .- ��-1he Conirador's�License-(awJ.: , .�.,cf _ .. . . . � � , ::: ..;.'_, '_'__'__'_'_ ___..�.':�__-_"-_______._.'_____. �.�� ANT45YPHONVANE � ... . ' � �. � -� ��- �- . , . ❑Iamezemp�underSec. .B.,BP.C.forlhis _�. ' ,. -.,, .-, '...._:,•'.rt. � _.____�.___..._ ___-. ...____..__ .. ,'.. EtECTRIC WIRES � � �� reason . . ' FE�JCE(HEIGHi) ' � ... ,..- �� Oa�e . .., .- �iOWncr:. .. .... . SELF-CIOSING 1 ' 1 .. GATES t5ElF.lATCNING J : t'�� . .. ��,..��,�, " :. :: ...� � • . . .. INSPECTOR'S NOTES� .�,: � � . . .. .. � ... r._ .� .. . �, �� ��� . � ' � , _ . . .. . � ._.f . . _ ROUGH WIRING � � .;� . �,�i �. ._._ � 1�.. . ,' V� ��t'J .. .. , . . - �,. . FINAIELECTRIC � �` �� •� •�." .. .�....�,� -. ..____. . .'_.--_ _____" ..___ . i . _... ._..__ '_ _ .E 1., �� � .. .,. , . . „ _.. . . ..., . , n , ... . ,.... .....�� � ____.___.. ..-_._._'__...._._... ' __.___ _ .__.___. ... ; •. �. � .� ..__ : _..._ HEATER(LOCA710N S VEM) ...`.". ..."....-'--�.. ..-.._..__,.... '� . . . � GASLINETFS7 =� '. �• .... ' .. "".,. . ..- POOL DRAINAGE I .. . .� •. .. ,:'! � . ; . . . . . . . . . . , _ ,,.�., , �. , ;... �. _ __.. .___�._.____. _-_•-____. .__' '_______ _' . , ,�" - . . :..,,�, ... . . .. . ...� ., P.TRAP '_� l ` , � - � �' � � :�. �. . .. . .._, ._.. ,, ._. .. ,. � ......,I,, � . __ ..;_. '...J . , ;