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Home My WebLink About1098A 1264A p-- W�RKERS COMPENSATION DECLARATION � � �� - ' � ��r - ,� � � � �I .....,. ..... . . .. .. .. ....... �....,. ... . :...,. ,::m_...�w. ..,,.. I he eby a'fim that I hove a certificote of conseM to sel4 � �'� �; ._ Insu e r o certificate of Wo kers Compensotion Insuronce,�� ZOB APPLICATION FOR COMBINATION SWIMMING POOL PER, ,, or a cerffied mpy ihereof(Sec 38 La6 C.) - .. . � � , � ' . � ` � y� ' �"97d,3 Bni Policy No.�1c.d8LCompany COUNTY OF LOS ANGELE$ BUILDING AND SAFETY � Ce tified copy is hereby furnished. . . �� '�� * w�'y�,��m � � � FOR APPLICANT TO FILL IN � � guuoiNc Certified copy is filed with ih county building inspeo � ADDRE55 �iion deporfineni. ) gUILDING � ' �� '� � /�-'� ' ADDRESS � LOCALITV "' ....... ......... . Date. � `Applicont , . � NEAREST � � � crcv zia ceosssr. ,J U12� ��' � C--c� �CERTIFICATE OF EXEMPTION FROM WORKERS' � � �� SIZE OF � ASSESSOR � � � COMPENSATION INSURANCE �-� �'�� - TRACT LOT LOi NO. MAP800K PAGE PARCEL This secfion need nof be com le4ed H�fhe ermit is For one ----�-�-� � -� � - I P P . . . .7E� � .. .-.......:. USE ZONE MAP � � (� ' hundred dollcrs(S1D0)ar less.) . OwtdER NO NO. �� O �� I certify ihol M ihe performonce of 1he work for which ihis � � SPECIAL ��' ��-- � �� -�`- permit is issued,I sholl not employ any person in any manner ADDRESS CONDITIONS � � - so as to be<ome subject fo the Workers'Compensallon Laws. ' ' " - '�-' '-" "' DISTRICT STRTISTICAL CLASS � TYPE PROCESSED BY . CITY ZIP � CONST. Dofe Applicont ARCHITECT OR "' �'TE� •�'��-'��-��"�- �� CLASS NO. � NOTICE TO APPLICANT: If, ofler making this Certifica�e of ENGINEEa NO � ��(�. Exemption, you should become subject to rhe Workers' ` VAtUATION , Compensation provisions of,the labor Code,yoo�must fo�th- A�DRE55 (,�.� ...."' '.. ..'..TEL ..-..../] ..'., VASIDATION with comply wilh such prov'isions or 7his permif shall be CONTRACTOR �� NO. �[� S deemed reyoked. ,,,,_, . LICENSED CONTRACTOR$DECI.ARATION„ � �� I hereby affirm rhat I am Ilcensed under p o isions of Chap�er 9 ADDRE55 NO g (<omme�cing with Section 70W)of Diwsion 3 of thQ 8usiness CITV-�� CtA55 ond Professions Code,and my license'is full force and effec�_... DESCRIPTION OF WORK � �� - � FiNAI , ► .. . ..... . . ., ...... n Lice e Numbery�_L Closs� SWIMMING POOL , � DATE � lv y Q}_' . j�,, . � � SPA -� • . . � I O Ci (�ii O �V I��rJ.� Date : ._�.. FIN . ,+e a s e . U ConiraGtor . . SQ.FT.. .... . . � � • � � I am ezempt under Sec. � ��-' S12E . . . , gY � r � O B.&P.C.�for this reasori - EIECTRICAL �y�� Q,^--�- ' � e � ��4� . U . D t �._. ... . „7 l. J�� W . � �� -��"'� "�� Steel 8 Conduit Bonding `� /� 0. Signo�ore � ... .... Conduils,Cond�Uors,Equipment � �--�" �� C�+""8 FS. Z . SWGLE FAMILY — . HOME OWNER-BUILDER DECLARATION PLUMBING � � I hereby af`irm!hat I am exempt fram ihe Controctor's license Law for the following reason(Sec��on 7031.5, Business and p-Trop � Professions Code): � Gas System 5 L �! � I,as owner of.the property,will do the plumbing and A�nti-Syphon U � � electriml ork.I,or my employees with woges as their �f�� . sole compensa�ion,or a licensed contracior will do all MECHANICAL � oiher wo k and�he structure is no� tended or offe ed �L Tt3'�L$ - �� I c�.��>n for sale-(Section7044 0&P Code). � �- �� Swimming Pool Heater � � � � CONSTRUCTION LENDING AGENCY � � {1= 4, a s e-� I here6y aft rm that there is a consiructio lending agency for � -� �� APPLICA TEL � � �,C.1'�.'�'.. rhe performance of the work for which�this permir is issued (PRINT NO , �(Sec 3097,C v.C.l. - � � - . _ Lender's Name � � � ` . ... ........ .........r.. ......... ADDRE55 r. . .,. ..... . . .. . ..,t, .. .� ' _..�� Lender's Address °`j ,p� L�� v� . . . . ......._. ....�......... P.C.Fee S � `�k l� Permit Fee ��;�'L� I certify ihat I hove read�his applicotion ond state thot ihe � - -- above information is correct.I ogree to comply with all Couniy Isso ce Fee �.d.-��' crdinances and 9a+e laws,rela�ing to b��lding, electriwl, . . °" ... .mechonlwl and plumbing construction,ond hereby authonze invesrgaron Fee �� -p-�� -�� "��"� r sentotiv s of �his Couny ro enter �pon the obove- 7o�al Fee {5 �+ ��^ me d ropert�f inspecllon purposes. . .. . ..- .... ......... ....,-....... . .........,_ ... . ...,..... _ ... . . . ... . .,.,,_._ ..... ..-. .. _.�... . igna .e of AppG<on�or qgem � Doie� 3EE�REVERSE FOR EXPLANAtORY LANGUAGE . .:. _ _� �:_ . . ' _.:...._ _;. _ _ .�,... ;..._>. ....PlANS TO APPLICANT �' .�.:� INSPECTOR'S NOTES �.�� ..�...-.. .:� �....� � � OWNER Bl11LDER DcCLARATION �To: . ��eturned �I hereby *F n'� lhat I am exe p from ihe Con!rocto�s � ��License Law,'#or. +hc.follow g r�oso,n ,Sec. 7031.5) Approved 8usiness and Professians Code:Any city or counfy which No.I �are No. DOTe, .. . . .. . requires a permif to construd,oRer,improve,demolish. � � ��--� - � �- �� ..._. � or repair ony sirudure,-prior�o i�s issuance; alsa re- .�� t�- .�. _; �` . ., ,. --��,.-� ;� ��.' � quires ihe applvcoal.lor such permi{to S1le a signed sfate- � ��- - . - . �� . . , .... - . ment.that he is ficensed pursuoni/o fhe prnvisi4ns of 1he i � . �-"�-�-:- Contraclors Licenselaw;Chapler 9)�(commertUng with , Sect'ron 7000)oi Division 3 of ifie Business and Profes- � � sions Code)or tfiai he is exempt Ihere�rom and the bosis . . �. � .-:._. .�.. . ..:., ... ... _ �.,;.� ...�.. . , -.,.. for fhe a/feged exempfion. Any violafion of Section INSPECTION DATE� I ECTOR . � �� 7031.5 by ony opplican}for n permit subjecfs the appl7� � � can!to a Nvil penalry of naf more tBan five hundred �ocwnorv doHa.s(3soo).): -'' ' ' � . ❑I,as owner of the proper?y,or my employees with SiEEL 8 FOeMS woges ps the!r sole compensation,w�Jl do the work,and LIGHT CONOl11T �� j�. , - fhe structure is not-ntended or offered for saie(Sec.7D441 �_ ��/ Business and Professions CodE:The Conlroctor's License �sON�ING i�; Law does not apply fo an owner of properiy who builds or " ��' � � - � improves ihereon, and who does such work himsel(or � � . . � �� . �thraogh his own employees, provided that wch im- � �- - - � provemeNs are na� inPended or offered Ior sa(e. If. ��__��(��.�y��_ � � however,the buildiry or rmprovement is sofd wi�hin ane �[oNOUIT _ ' ""� � year of compfeaon ihe o.vner builder wlfl hove the �/'l . �.:�� : , . . burden ol proving fho!Se did not build or improve for the - GAS LINE �-�� purpose of sole;. , ,. ` � . ��I,as owner o�!He-.proPeriq,cm ezdusively con- WA7ER IiNE �_: �,/ '' �' octin �'F.;'��ersed<on!r�c ors�o construc�ihe projec+ �� . �S<,.�70441 8�� ness a,d Profess ons Code��7be Conirao- SEYd�R I � ro's�L cens.Lov+do nof apply{a an`6wn8r of p�rooerty � S �, ,J r � - �" ho bu!ds or mpro es ihereo ond who contracfs for .i � �� such proteds wi�h o mntroJtor(sJ licensad pursuant ro � � � � � ' �he Contrador's Cicense Caw. � r �ANTI-SYPHON VAI.VE I � � ❑I am e�xemot under5ec._—,B.8 P.C.for!his r ELECTRiC WIRE$ ! - reasCn FENCE(HEIGHY) . .''�:'� °{ d'�^' .. - Do`e O . . � ti.y .. � . ... . .. . GA7E5 (SE1F-QOSING } .a-'} � #+,E i�s'� � IfVSPECTORS NOTES �SELF�LATCHING f � � d u% �} �� ' �ROUGN WI ING • '•� . . :.:....�........... ... r �FINAL ELECTRIC . .....,....,..._...................... ..._....,,..�........ .. ... .. I _ / ___ �HEATER(LOCAYION&VENT)� ,.y�:,� �� . � �� y� ` I, ' . ._.._ . . ' _ _ �.-.,. .. .�,..�. .... ., � �GAS LINE YEST I:;,,�L''{! ��.....��f_;%�„ ',"t f'. I P003.DRAlNFlGE '� . " � . ..�� . . �..+.. . � P�iRAP . .,. .. .... .... ............... .-._.r::. �..r..isi.� �....�_ . . �' . ..,�.., . .r#+4Nasw"`�v.� ., .:.,...,a,; �Pt K�' Y d�E .i