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HomeMy WebLinkAbout1239A 1667A (6) WORKERS'COMPENSATION DECLARATION �� ���� .-�- -� , .. I herebY Wifirm thnr I ha e a certif care of mnse t to self ., .:. '...... ...".. . '� �-..'.' ...� ".--:. ._:...^* . � .� . ��s��e or o cerhf ca?e.of Wo kers'Compensai on��s�,a��e; ° APPLICATION FOR CO1VlBINATION' SV1lI�l�I�IG POOL PERMI'� .o a c<rl f ed wpy fhereof($ec 3900,La6.C.) �s,�20R . . . . . . ' .. ..�:a . ....., .,,..._.., .,..__..., . � � � CE9]di5:d<� � � ❑ UNTY OF LOS ANGELES BUIEDfNG ANQ SAFETV Pohc No.� Com Certlf�ied co s filed N,t�rnished. ��" � � �- ' ��� �-�- .::,. �.�,: . pv� v _ _. FOR APPL _._ ..�. .._a.._.�., euuoiN� r _'.. � �nrhe coumy 6uiiding Inspec- CANT TO RLL IN N .400x�55 �'�'� � �C �Cv1�.Q r,t7 tion deparfinenL BUILDiNG � �(� � .... . ..._n....... . � . � ADDRE55 LOCq!!Tr (Jy ^ �jnN Qa1e . . ApplimN . .. .. .. . . .... . . . . .. . .... . ..,.__ �.., . . .. :.._._ . ,. NEAREST �� .. CITY ZIP I �� CRO55 ST. � ��. � CERTIFICATE�OFEXEMPTIONFROMWORKERS _... .. ._... _.. ..:. . . � COMPENSATION INSURANCE�'" ` ��� 9ZF OF - -�- ASSESSOR � �-��-• ....r_. TRACT � , LOT LOT NO. � MAP BOOK PAGE PARCEI � (This secTiom need not 6e compleTed�f the permi��s for one ��� �'-' '-'�-'"����TEL USE ZONE nMP -�-"�-"""�t��') " � hundred dollars(5100)or lesz.} � OWNER � � �. ' � NO �� '�+,� �3 � NO. ��� � �M1 T( work fo h'ch this . .. . `:". SPECIAC . .... . ". .. I<er�i{y thor in�he performonce of the � � � - � . permlr is issued,I sholl not emp�oy any person in any manncr ADDRESS YV� [`~ ���' COPJDiTIONS � so os fe be<cme spb ect rc!he Werker'Com e ation aivs. " ' ��� �� �""""��- �����*_' ' -�-r��-w � � P GTY �j�W(N�I�'C.^ D!$TRICi SYqT15T1�ALC[A55����' NPE'- PROCESSEDBV . . ' �: Z:P (,C� � CONST. Do'e�f��/$7Appl�icant ARCHITECTOR "�� `�'�" ""^"'.""'-'�� .r/y �(+ GLA55ZNO � NOTICE TQ APPUCANT:,If, after� g . � mok' S Certificote of ENviNEER � Np. —�"'� V 7 E.empt on, you should become'su jecf to the Workers' � � � � ������-' � ��� � ���� �" � � � � � � -Compensation p ovisions of the Labor Code,yo�must.forlh- ADORESS j �Z � VklUAiION wth comply wlh such provisions er this permir shall be. frG�"LS �� El S VALIDATIqN deemed revoked. CONTRACiOR C� NO.��.�} (� - . .. . . ...,. .,.,.. "LfC. � � ' . � . . � tICENSED CONTRACTORS�ECLARATION . ..,_.,,., qDDRE55' `l � NO. ��` � � _.m._ I hereby aKirm lhor I pm„licensed unde p o sions or Chapter9 _- ..-, ' ",�•_ L�C _'.`...,"`.""`.," f (mmmencing i�h Set�ion 70001 of�D sio 3 of the Bus ness CITY v ClASS �i-� ond Professions Code,ond ny�c.nse � II°o<e and effer,i. � DE- WORK ��� � �-������ '�-�,—,�j L cense Number �1�7 M�� �c Class � �3 ' � X FINAL (`� ► . '-� � ?�:C)h . . . - , _,. y...,n,A..� SWIMMING POOL ��—Jy DATE � �tj � . �-�/1�.CC7 YUlL�7C�Y'� Z � SPA ' . . lJ FINAL � ✓r• a a •2� O Conirocicr o e � . .. . . ,._..... . . ..... - SQ.FT. � eY � ( � ; .�l I�� S V � I am exempt under Sec. SiZE ,;�,Z � � -�. 6.&P.C.for ihis reason � /�e� 1 p f " ' 2 O . . . .... ..� . ......, ,._ ..:.,._.,� ELECTRICAL .rd'l.(.�r1 �rLTi.^,� � �,� I, i J c� �U _.. Date � . . .. �D J-i ='�l� W Si a�ure � - Steel&Conduit Bonding �I t_ .� a 9n SINGLE FAMILY �� ' "' Conduits,Conductors,Equipmem ./-S �}' G � Z HOME OWNER BUILDER DECLARATION � PWMB�NG �� u L',�I A I hereby afflrm Ihot I om exempl from fhe Coniracto s License� ��[Y. �C U! (y !�.diG� � � Law for the following reason.(Section 7031.5, B s ness-and �r�..Epy}�t„qqyp/J-r/l/.)r�� , . . }I A o m 3 e� Professions Cod?): P-Trop � Gos System � A,<v C,�v � I,as owner of the properry,will do.rhe pl�mbing and Anti-Syphon [i eieclnm l work.7,or my employees wifh wpgesas fheir Q �'`!�,v�� e sole compenwtion,or�o licensed mntradqr,will do all MECHANICAL , ' other work ond the s�ruclure is nof imended or offered�� � �a.i ���7 for sale(Sec�ion 7044 B&P Code). ��� Swimming Pool Hea�er 1�kK"S . CONSiRUCiI�N LENDING AGENCY i{(7O�CDC �'7"D . I herebyaffir that'here :a construc o lending agency for qppLICANT � � ����� �`A`�E� '7� the qerforma of i wnrk tor wh ch rh s���erm�f is issued p� �n . P . (vRINTI Sr{�.'� �� E' 7r� NO f d�?�6 ► (Sec 3097 . . � . . . _..... .� ..�...,w.. ...y,,.:�.,,..,.. .,.�..,.. ..:.._ . /�'!i�'YL�"'�� ie�ders Nome. �ee �� ADDRE55 Z.-�IIZ.1 �-{�i1-(C.lMt'�ij'a G'[' ,s ..... .._..,,... . . � Lender's Address_ .,, _ , � . ..,,. p,C Fee 5 Aeimir Fee �l�o��� � I cerli4y tha!I have read�his appllcat on a d stote that�the � " above informatlon is correct I o�ree to comply wifh oll Ccunfy � ce Pee 1�}, � Q � a d nces a d Sra�e laws relating to bu7ding, electr�wl, issa4n ......... ..,.,_,..-... . . mechoniml o d pl mbing o si.uUion.ond hereby aofhor¢e �esrigarlon Fee �� v S� - rep e.entcaives of rh s Cc ty to enter opon ihe above� ioiol Fee m nt� d proPery for inspectiqn purposes. ..:.._ ......._..........._..........,:..�, .:,.:.,.m nu....:;�,:�., ,�:..,.:.�v� �u.,:.::a.r._ ...:.,.va�,�,. - .... ...... ���� , .: _ . °�, .i�-t��.-! S�gco�.;.e of Avnlico�i-o tgen�""" �°�� 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 , ..-�...:. ..:..:: ��.��- ,��- �