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Home My WebLink About1346A 1347A (7) WORKERS'COMPFNSATION DECLARATION- -� �� ' � �� '�� "'"� �� ', -�� : . -'t . �. � ��-� � .. I hereby affirm that I have o ce tifiwte of consent to self - -�� , �,Mx, y,ri..��, . ' insure o a certif cote of Wo ke s Compensatlon Insurance,� � APPLICATION FOR COhA�INA�"ION SW'IMMING�P00! P�R19A��'�`�"� .; or a cert f ed copy ttiereof(Sec 3800',�j Q.1��-{J��r' � � �,6��oB � '�-' " �� ` � � - rl'�_2`�'0 ��.PJ 1-�-c�/ s�9[s aai . . . . . ': Poli<y No��' , Cqmpany . ... ..._. .. .- .-. COUNTY OF LOS ANGELES� - �BUILDING`ANb�SA�ETY� �� Cert�ied copy s hereby f�mished . . . ... .... ,.... . : ..:..,,.d.... -. ,,.,»...,,.f.....,...�...... �r�.�_..,.,..... ..�...._. ,�:.,.��-:� . ,..,-... . .. .... _,.._.._. �9-�� FOR APFLICANT TO FILL IN euaoin �a��3 ' � � Certified copy is filed with ih couny buil��.a o- ADDRESS f on epart ent. BUILDING " , � G��i�GGCI� ` ADDRESS �o�ao2 S� ' �OCq�i7y DatA� Appliwnt � . . � NEARE5i�.. . � � CITY ZIP CROSS ST. � CERTIf ATE OF EXEMPTI FROM WORKERS' ----�-�-�� . . . ,.,,, .-_..„... $IZE OF � COMPENSATION URANCE ASSESSOR -� �� TRACT LOT- LOT NO. MAP BI�OK PAGE PARCEL {This secfion ne¢d no1 be complefed if trhe permit is�For one TEL U OY MAP hundred dollors(5100)�orless.) � OWNER �rp-G'��iJ NO. `e��,s�y2.6/y� �� NO. . ��o�- .I certify thor in ihe performon<e of rhe work for which this SPE[IAL permif is issued,I sholl nof employ any person�in any monner ADDRESS - '�C� �^�� CONDITIONS� � � � � . �ISR:CT SiATISTICALClA55- -�� TVPE so as to become s�bject�o the Workers Compensation Laws. - � � � - � � PROC 8V � CITY. . .21P.. . � -Dote Applicant ARCHITECT O 7EL c� /J CLA55 NO. 2� CON57. NOTICEiO APPLICAN7: if, after�making this Certificate of ENGMEER� �' �n+-- No. � C3:ZL/� O`"'�- eJ E'semption, you should-6ecome subject lo lhe Workers' VREUA710N -� - Compensation provisions of the Labor Code,yoa must forth- ADORE55 (J' � '1� � L�� p- . with mmply with such provisions or ihis permii shall be TEL. - � � s } /11/`l�—) VALIDATION deem.ed.revoked � CONTRACTOR iJ.s� .NO. ��^ t (�1� " ' "�'�� '��" �� LICENSEDCONTRACTOR5��DECLARATION ��-� �� '- �$�,.b _-�P -.��0.�2��^��j I hereb affirm thai I am licensed under - AODRE55 0� ' y provisions of Chapier 9 �� 2�� s .(commencing with Section 7000)of Divisian 3 of the Business ClASS � �� ond Professions Code,dnd.my I ce se�s in�full force and effecL � �� DESCRIPTION OF WORK� � I 1 3 4,6 P, � s7? �s 3 F�N�� License Nu er� �� Lic Class . SWIMMING POOI pA�E ► �o o w e�� r , �' Contract. Date � SPA . . . FINAL � � s o(fj Q,J(� Q. sca Fr � eY U � I am exempt under Sea SIZE & Q �y.y,C 9� � � 8.8P.C.for this reason- � . � .. . ELECTRICAL. . . . �,.__/ ��. � . . �.� � `�'��` 12L3—�� U Date: � W �-Signniure � � � � Steel 8 Conduit Bonding �1 3 4.7 A N Conduiis.,Conductors,Equipment Z SWGLE�F,4MILY �c a e o e 3 HOME OWNER-BUILDER DECLARATfON �� PLUMBING i here6y affirm thor I om exempt from ihe�Contrpctor's License ► � 0 1 7 5 5�6 �Law for the following reason(Section 7031.5, Business and P T�a �Professioni Code!: � - - � p � Gas System ° d � 7 5.5 V 2 � I,as owner of ihe pioperty,will do ihe plumbing and An�i-Syphon . � � eleciriml work.I,or my employees with woges os fheir I 2:�3—8 t� sole compensafion,or a licensed contractor wiil do oll MECHANICAL- � � �� o�her work and the structure is not intended or offered for sale(Section 7044 B&P�Lode).� Swimming Pool Heater � �. CONSTRUCTION LENDING AGEN'CY � �� I he�eby affirm tho'+here is o consrrudion lending ogency for APP��CANT 7EL � � the performonce af�he work for which rhis permit is issued �PRINT� . NO. �(Sec.3097,Civ.�C.1. . ._. . ..._...._... ... �ender's Name ► ADDRES$ !ender's Address j� / C �--� � P.C.Fee 5 ��j !/ Permif Fee /[O C] � �G' I cerlify that I have read rfiis applimtion and sia�e thot rhe� . a6ove information is correct I ogree to mmply with oll County Issuance Fee �� ordinonces and Sfa�e laws relating �o building, eleUriml, mechanicol and plumbing construcrion,ond hereby authorize In�esrlgono�Pee � - r ese c�i- s of thi ou , to enrer u bn the above- To�alFee �� m -on pr erry f r�nspectio purposes. � ` ,....�. ... .... .. _. .. .. ... ig w. o app-mn•o� ge�r Dai SEE REVERSE FOR EXPL'ANATORY�LANGUA'GE � �� - � -� - � �- - � �-� � � � .. ��PLANS70�APPLlCANT".'.... ""...".. .":��"' : ....��IRJSPECTOR'S�lYOTES.: . �. . .�.. . . .," '.-'....'`.� OWNER-BUILDER DECLARATION. . � 7m � i ��-�Returned -��-' �-"...- ",^`".' ""-°�, heroby aff rm tnai I om e emp�°rom the Ccn�ractor's . '-' -- �� License Law fo �'he follo q e�+sr (5 7031.51 --- - Approved .. . "� - � ��-�-- . � Bos'rness and Professlons Code:Any city or co�nty which No. Dote �No. Dafe requires o permit fo construd,alter,improve,demolish, � -�.-..,•,-. .. ..-....,-..-. . .-.�-.`.^..-- :,:��brrEpoir any structure, pnor to ns issuance, ❑!so re- I ' � quires fhe applicont forSuch permrt to file a signed stafe- I � ... . . . . . . . . .. �.`...'^..... . '°.,.",.^ �....-.-...^-.....,.-.�..,ment fhof he is licensed pursuanf lo the provisions.o(�he � i � Coniractor's License Low(Ghaptor 9f(commencing with ii , �� - -��--��-------�------�-�^---�-�- ' Sectlon 7000)of Civision 3 of Ifie 9usiness ond Pro�ev Lsions Coo'eJ or ihaf he is exempt fherefrom and the basls .. . .... "..... . .. .. .... . :.'..` :. ��. �.-. � . . . . .... ...�-�• .,;:�.-: for the.aNeged exempfion. Any viofation oi Sec�ion � � � � 703L5 by any opplicont!or o parmit subjecfs The appli- INSPECTION � � �� INSpECTOR:� . ��-�� T ��- ��•� canT fo a civil penahy of noi more thon Iive hundred LOCATION � dol(ars(5500;.).� I / � � -' �-��- -��•�� ^��-=� ❑i,as owner of ihe property,or my employees with �STEEL 8 PORMS� - wages os thelr sole compensa�'on,wlil do the wo�k,tlnd ��- . ., . '� ' • �"��'�-� - -�-� �� ihe structure is not intended�or offered tor sale(Sec 70441 -UGHT CONDt117 i �' � � � . . Business and Prolessions Code:The Con�racfor s License BOhDING � ; �� ' � - ��"�" ''''�"""`�"' "" "�"'""""��""""" tow does noi ppply fo an owner of property who builds or �� improves ifiereon,and wh �d es such rk bimself or � � � . ��- - � ��-<- � . ihrough his ow� employees o owded that such im- .. . ._.._.. .-.,.,. .... 1"'-- —'�" - � provemeNs ore nof �niended offe ed f sale. !f, - � . � � ' �� - ` ��-- however,?he SuJd ng or mprovemeni is-sold within one . i. - � �- year of camplehon, rhe owner-builder wrll have tbe '� �.CQNOUIT �'„i �� .--�,:�� ---<.._,., ....,.,�,,,.,, .....� burden of proving�hat he.did not 6uild or'rmprove for the � � �� ' � � ose of sale;. - GAS LINE .,. purP � � . . �' .. � . . . , , . . . . �� ' ��-� ��-��--° �.��'- �.I,as owner of'he property,om exdusively con- ��i WpTER LINE _�, �� ' i-oc,;r.g w�'h I:cc^.sed contr�c,ors�o consfruct'he prajec' • . � �. o � � �� - - -�� - �� -�-��-.--�� -�� i5e: 7044)Busmc-ss ord Professions Code�ihe Contrqr � � i SEWER �� 'y�� i . � � tor"s Licensa to•ro does not apply�o an owner of property I• �� -�-�� -� -- •.v.��.- ..�-�W.�� --•..-,�. who buifds or mproves thereon,and who confracts/or L� � such pro�ects uirth v conirottor!s)fitensed pursuanf fo �� . . � . - �he Confrac%or-s L cense Law� � .. ' ��ANf TI�SVPHON YALVE � r . - ...,.. ..�.. -._.�,....._- - . � ��-��*�- -�-��❑�:am exempr��der Sec. .B.&P.C.�or this j E[ERRIC WIRES . . . , . ,...«.,.s .-.n:, .....,...� .,, . . _ FENCE(NEIGHT) �d[ �e Date _ Ovne ... ...,._,.:...:... .. . . ., . .. .. .. .... ....... . .. . ..'" .. SELF-CIOSING � � . .-•,.�.....�..-.,. GATES ('SELF-LAiCHING� �NSPECTOR'S NO4E5 ,:��f %�z� �l/�' . _. . ... _.,r.�„ ,... . ., . , -- �GH'NIRING I `✓� . , .. .. . . . . .. -.,. ...._ ,.�. �i . ,.. . �D � . ..:.. .,.-.. .�,.».. � FINA�IC /�'� . . ...... .. � . I ._... _ . . . . . . ... .. - . � .- . . ,.. ... ..... ....».,,-.,.wry^..,. ., .. . . .... . �. ..:..., .. . . . _ ... . . . . . . .:.. . . . . . �HEATER ltOCATION$V.kT) ' . _. . . . � . ... �. . .... . . .. . .- .:,... ,........... ::.�__.._ ... . .., . GASIINETEST � � - „ ...,� ..... . .... ...... . ... . .:........:. �POO?DRAlNAGE � .. ..__.. ., . ..,_ ...:. — . .. . . . - I P-TRAP � . . .. . .. ... ......_. ........,..s� ,�,:._....,,... . �.—___' �..,��. .,,:......,.�.,,,,.........,..� «e,,:.'av::..�:..�e�,,.,.,. , . .. ... .. . ...... .. .... .... .. .. . . ...._. ........ . ...... ....: � .�.. �...� . � .. . .. ............,.. ,,.n�.,;.... . .. . . ... ...� . . � . - .. .