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HomeMy WebLinkAbout1239A 1667A WORKERS'COMPENSATION DECLARATION �� ���� .-�- ' , .. I hereby!^firm rhnr I ha e a certif ore of mnse t to sel{ � �'�����'�� ���"�� " '� ���-'�"" "� --���,^* • � ��s��e or o cerhf ca?e.of Wo kers'Compensaiion��,�,a��e; � APPLICATION FOR COAABIN�TiON' $V1l1��illill�I�IG POOL PERMI'� .or a cerl fed wpy fhereof(Sec 3900,La6 C.) �s,�20R . . .. . ... . ' •. ..�:a .. .....�.., .,,..._.., .�...__..., . � � � CE9]di5:d<� � � ��Ce�'ified co s hereb f�mished. UNTY OF LOS ANGELES BUIlDfNG ANQ SAFETV v ��y CO : : .::.;. , :: . _ PYi .. Y .. ._. . . .. .:, ,._.... ._ ............a,.,�.�.,.,. BUIIDING ,. .r.. ._'.�._ ... , .� Ceriified copy is filed with rhe coumy 6uiiding Inspec- FOR APPUCANT TO FILL IN .400se55 �"Z'� � .�C. �Cv1�.Q r,tj � f�on deparfinenL BUILDiNG � � �(� -� � .... ......_n....... .. � . � ADDRESS LOCq!!Tr (Jy �jnN Date . . ApplimN ...., . .. . . ......- - NEAREST .. .. . ... . . � . .. . ..... . . ...... CITY : � ZIP I �� CRO55$T. ...�. � CERTIFICATE�OF EXEMPTION FROM WORKERS _... .. ._.. _. ,,;. � COMPENSATION INSURANCE�'" ` ��� 9ZF OF � ASSESSOR � �-��-. ....r_. TRACT � , LOT LOT NO. � MAP BOOK PAGE PARCEI � (This secTiom neQd not 6e compleTed�f the permi��s for one ��� �' � -"�"���TEL USE ZONE nMP -�""�-��2""�t��') � _.. � hundred dollars(5100)or lesz.} � OWNER � � �. �� NO �� '�+,� �3 � NO. ��� � JM1 T( work fo hch this ���� ' '���'� SPEaAt � ���� � "�� �- I<er�i{y thor in�he performonce of the � � � � - � . permlt is issued,I sholl not emp�oy any person in any manncr ADDRESS YV� [C ���' COPJDiTIONS ' so as fe beccme s,u6 ect rc!he Wcrker'Com e ation ativs. G7Y �j�(A�(N��L � ���� � ��^� � �Y�� . .. � P , � ,.,, " ' " D�.STRICi S7qT15TICALC[A55����' NPE'- PROCESSEDBV Do!e�. --�(p. '7 �: Z:P (,(' � CONST. -J�9!Applicant ARCHITECT OR ""�� `�'�" '-""`�.'-'�� .r/y ��R, GLA55 ZNO � NOTICE TQ APPUCANT:,If, after� g . � mok' S Certificote of ENviNEER � Np. —�g V 7 � ....._ . . . . . . .. . . . .....,... ..., . .. . E�emption, you should become'su jecf to fhe Workers' � � - ���-�� � � � � � � -Compensation provisions of Ibe Labor Code,yo�must.forlh- ADORESS j �Z � VklUAiION wth comply wlh such provisions or this permil sholl be. frKTrz�s �� EL S VALIDATIqN deemed revoked. CONTRACiOR C� NO.��.�} (� - . .. . _ ...,. .,.,.. "LfC � � ' . � . . � tICENSED CONTRACTORS�ECLARATION . ..,_.,,., qDDRE55' `l � NO ��` � � _.m._ I hereby aKirm lhor I pm„��censed unde p o sions o�Chapier 9 .- ..-, ' '�.�•_ LI� _.","...'".'.'_.,. f (mmmencing i�h Settion 70001 of�D sio 3 04 the Bus ness CITY v ClASS �i-� ond Profesvons Code,ond ny 4cense s � II°o�-e and effer,i. ' . . . .. �{ /]�( ' , DE WORK ��. ,,.,.. "_',_,'j L cense Number �1�7`f�� �c Class L S3 ' � X FINAL ("� ► . '-� I ?�:C�h SWIMMING POOL �J DATE � �tj � jiF /]��,� 1[�p� ��✓y� Conirocicr�CC],1'UI.CJ�Y'lWote•• 'A��Z`��.: SPA � . . l_J FINAL - �r• a a •2� O ❑ .. .. SQ.FT. i . BY � , ( � ; {�J L� J� V I am exempt under Sec. Si Z E ;�,Z � -�. 6.&P.C.for ihis reason � �t� p f " ' 2 O � :� �, I �7 U . . .... ., . ....... .. ..._ ..:..,._.,� ELF.CTRICAL .rd'l.(�r�y �e'L.�S.^,� .F' .....Date � . . - �b J i �Qj�] W Si a�ure � - Steel&Conduit Bonding �I t_ .� a 9n SINGLE FAMILY � ' ' "' Conduits,Conductors,Equipmem .PS $' G � Z HOME OWNER BUILDER DECLARATION � PWMB�NG �� u L',�I A I hereby affirm Ihot I om exempl from fhe Coniracto s L�cense� ��[Y. �C U! (y !�.diGiJ � � Law for the following reason..(Section 7031.5, B s ness-and �r�..Epy}R,qqyp/J-r/l/.��� , . . }I A o m 3 e� Professions Codnj: P-Trop � - Gos System � p,<..C,y v � I,as owner of the properry,will do.rhe pl�mbing and Anti-Syphon [i eiecirlca l work.i,or my employees wifh wages as fheir Q �'`!�,v�� x sole compenwtion,or�o licensed mntradqr,will do all MECHANICAL , ' other work ond the struclure is nof imended or offered��� � �a.i �—�7 for sale(Sec�ion 7044 B&P Code). � Swimming Pool Hearer �n'`S . CONSiRUCiIQN LENDING AGENCY 1{(7O�CDC �'7"D . I herebyaffir that'here .a construc o lending agency for qpp�ICANT � � ����� �`A`�E� '7� the performa ce of i wnrk tor wh ch rh s���erm�f is issued p� (Sec 3097 . P . (7RWT)Sr{�.'H� ��.5 E �� NO f d�?�6 ► . . . _..... ... ..�...,..... ...y,,.:�.,,..,.. .,.�..,.. ..:... � � /��3�i'LI-.."�.s'� te�ders Name °ee �� ADDRE55 L t 2.1 �-�hn-ICi'�'�� GT v _..,,. � Lender's Address - ''' - ' ' ��•-� P.C.Fee 5 Permir Fee �l�e��� � I certi4y tha!I have read�his appllcat on a d stote that�the � " abd nances�and Srai�orreci,I,o�ree to comply wifh oll Ccunfy � issaance Fee 1�}, � (f e laws relating to bu7ding, electr�wl, „ _ . mechoniml o d pl mbing o si.uUion,ond hereby aofhorize �esriganon Fee �� v S� - . �epresentorives of rh s Cc ty ta enter opon Ihe above� Taol fee m nt� d o ert for ins ecti � oses. ... ......._..........._,.,......,:..�, .:,...,..,. .:,��;. ,�._,...�. z.::a.r._ ...:.,.aa�.�,. � - ........ ...... ��rane or p�p qn purp ....._ . . � . _ ..,�, . ,.. y . . . � .. . � ) ._ �7 .. , , .. „ ... .. �` �N ' .��-���-' 1 � S�geo�.;.e of Avnlico��i-o tg���"""' �°�� Dore ' ' � - SEE REVERSE FOR EXPIANATORY LANGUAGE � '' .run..�.. .,u.. '.. , . _...�.:.. • �,.,^... ., y,�, .. . i. ..., .� :,.:... ,L. :'J,::3N_ L.+-..�J:.R;�G`]i W tP.':'.�� ' . ...:.. , ...,.,...... .....-',�. H,t-.� �,ir''�YVF>.iy�'�;' � PLANS TO�APPUCANT-� � � {NSPEGTOR'S NOTES 5 ���� OWNER BUILDER DECLARATION _.. —.�. . . .. . .. . .mc?or's �T � I her by rf rm th t I am xempt f 6m the Co To: , '. ReTurr.ed � - ens L for the fpl.low ng ason (5 < 7G31.5) .._ . ,. ..:... . Approved Business and Profess�ons Code.Any nty or county which �No. Oo+e Wo. Data . requires a permit to consfruct,alter,improve,demolish, � � . .... . .._..... . ... .._.._.................y.._... - . . � or repatr ony strudure, prior to its issuante, also re- � .. ,,...,,,_,.:-,.;.,.._..... � .,,..._.,., � qui�es fhe applicanf/or sacb permit ia 9ile a signed sfv�e- � � � � ...� � : ��� . mont tha�he is licensed pursuant to!he provisions ol fhe � � � �� �-� , . . � Conir clor's License Law/Chapter 9J(commenring wiffi , � � ��� � � � ������ � ' �� � �Secticn�7000)of�ivislon 3 of the Business and Pro6es � . . .. .. . , ,.�.:_.... ., sions Code)or Thof he i�exempt iherafrom ond the 6asis .. . - . . ..,._ ... ....... .... .. ....,�"�: ,..„,�....::,.�-..,,,,.....»*-r»...._..,...: ..:« ,. _�_.:.....-.... .. �.,.f,-._....:�.. .:�for �he alleged exemption. Any vio(alion oi Sec�ion . lNiPECTION �DATE' INSPECTOR � � - 703i.5 by ony opplicont for o permu subjects ihe appli- .... .. . .--- ...........�. ..,. ... . . , . � caN to a civil peno7fy o1 not.more iBan five hundred LOCATION " � - dollars(SSOOJ.j: � � , � .. ' .._ _.._.____._____._'__... ...,..._:... �- - � �[]f,as owner of ihe proper!y,or my employees wiPh STE'eL 8 PORMS � ' � � woges as iheir sole<ompensatlon,wiil do the work,and . � � the sfruUure is not intended or offered*or sale(Sec.704A;� LIGHT CONDUI7� . � . y,/ �-'� � ' � , - 8usiness and Proless s God 7he Confractor's,Llce�se l � . .. . ... . . . .:.....a.v..-e� .,...,........ . . . . . '�00RDING - , _ . � Lew does noi apply io an owrter o(property who bW�ds or . � � improves ihereon.ar.d who does,uch work him;eli or . - . .... ... ........_. ,,.._ - .... .. . � � �- �$irough hls����own employees provided that such im- — provemen7s are noi in'ended or oHered tor sa(e. Jf, � � ' � .�.,,. � � � �, � however,?he Suilding or imoroyemen+is sold within one '.CONDUiT � ';�j, � �iB� . yeor�of complefroa �ilie�ow�ner-builder wiN fiove ihe . ���-�burdenofprovingihvfhedidnotbuifdorimprovelorfhe GAS LINE - , . Purpose of sale!. - ' - " �WATER LIIVE . #��. .'`���� 7 � . �� ❑ I s own f�he property,am exdusively com Ij �� ->� / ..� ,h i���ce i ontaCoa ro�construct the p . �._ . ..__...... ...�..>...._. roiecr - �'Sec.7044;�Susin=ss and Professions Code:ihe CoM�ar SEWsR ' � for's Litense Lqw daes�not apply ta an owner of property _ � � who�bvilds or improves thereon,and who mntroc�s for . uch projeds wilh o mntroctor(sJ licensed pursuant fa s ._, ..._. ._. . - . ������-� � ��^.he Cantrac�or's l nse Low1. �P.NTI-SYGHON VALVE .. .. ... ......,.:- _....: .. ._.....--._.�._......___—... . ........... ... � ❑ amexeM.tur,tler5ec_ B &P.C.for�hls [LECZRIC W�RES ' -��-���reasor -� FENfE(HEIGHTJ . . .... Ja,�e.._ Owier.. .. . ' . . . . .., .. ...:. .... . . . . . GATES rSELF-ClO51NG } �� ' � � - � ' �. `SELF-�ATCHING I INSPEC40R S NOTES . ,o ,, - �... } 'ROUGH WtQlNG . . ���� ��c�� rFINALELECTRIt � '. . ,... ....., o,..... .:.a.�.....�r _.....,. .-... .... .. . .. , -. I � • ..e.........�:..�.a..�.m.mcar � .. ,:�� , , ,. . ... .. .,_.... ..._.. _.�.. �+� . .. I}iEATER(LOCAT101J$VfNT) � " GAS LINE TEST i - � ... ., ..,. ;._:.. .,;;,,.._..�.. . �POOI CRAlRAG6 .-- ..•^:.... . �P-TRAP . - .. .............. ...�..,... . ,�...,.. .:�_z�..� � ., ... . _ - � . L� .� �,.:;�.:.;.. . ,. -,...,.:. ...,....�., '' _ t �.' ... . ., ... . ....:. .. ..w;.r ,.�. _,.:w a...u......:,.. a , ..-�...:. ..:..:: ��.��- ,��- �