HomeMy WebLinkAbout1028 FAREL AVE (2) WORKERS'COMPENSATION DECLARATION 76A663 ,o�e, APPLICATION FOR ELECTRICAL PERMIT �
I hereby af(iim iha�I have a cer�ifimre of mnsent to self C6806G
i�sore,or a cc�iificate of Workers'Compe�smion Insuronce, COUNTV OF l05 ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,Lob.C.) .
P❑oliCy N0. Compony � FOR A►►UUNT l0 Fftt IN JOB � _ /��qy
Cerlitied copy is here6y fumished. EACH NO. FEE ADDRE55 �6R-iG�/
New Residential Bldgs.8 Pools
� Ce�lified copy is iiled with the munty building inspec- 1 8 2-Fomily,Sq.Ft. 5 — S LOCALITY ��(��T � C
tion deparlment. Mulli-family Sq.Ft. — NEARE51
Residential Swimming Pools �Ross 5T. �.c� Cb N you ,(oa o
Date App�icanf OWNEROR �//�_�� �J�. � h �!,
FIRM NAME H/'�' AJ 'U �/
CERTIFlCATE OF EXEMPTION FROM WORKERS' puders:Rec_Light_Sw._ �`�'A�� -�/i L
COMPENSATION INSURANCE ADDRE55 /� �
(This fMien nwd nol b�cemplN�d i/Th�work{nvolv�d by �' Firsi 20
tb�p�nnll i�for oM hundr�d dollun(SIOD)or I��s.) Totol No._LZ Addilional CITY (f ` Tei.No. 7 d- �J�
/
I certify thm in ihe performonce of Ihe wark for which this
PLAN CHECK
� permit is iswed,I sholi not employ any person in ony manner " � Pau ANT
, so os to 6ecome subjwct ro the Workers'Compensotion Laws. Li9hting Fiztures First 20 ADDRE55
� . - Totol No.� pddiiionol
CITY Tel.No.
Dole npplicant � Fixed Appiionces Not Over I HP
� NOTICE TO APPUCANT: If, oiter making this Ceilifimte of PFRMiT .
( Exempaon, yoo sho��d become subjea to rhe Workers' Ronge_Healer_D.W.— Aa�'LiCANT
Compenaotion pro ision of the Lohor Code,you must for�h- Oven _Dryer _W.M.— - ADpRES$
i with mmply withVsuchSprovisions or this permif shall be 7op _FAU _W.H.—
� deemed revoked. _ Hocd _ ' CIN Tel.No. .
;- - -LICE�JSfD CONTRACTQRS DECLARAAON- -- —Fan Ofher_ iCENSE OR --��-----
.___._. ____ ._ .-__- _ -___ . _ __. ._._.___ — __-___ ._.
1 I hereby offirm Ihol l om licensed under prodsions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER Closs.
� (commencing with Secifon 7000)of Div sion 3 of�he Business DISTRICI NO. PROCESSED BY
� ond Rofessions Code,ond my license is in full force ond eHect. Power Apporptus&Large Applionces � y
Size 8 Type HP,KW,KVA,ar KVAR IL �
License Number Lic.Class Up 10 1 Ind. FINAL V
Over I to IO lncl. DATE VALIDAiION �
Comrnctor Daie Over 10 to 50 IncL �� p ,
OFItJAL
I om exempt under$ec. Over 50 to 100 Inc. BY r/J�i� � W
Over 100
B.BP.C.for this reason , �$ • • a e� Z
Services,Swbd.,MCC 8 Panelboards �
Date: 0-200 Amp.Under 5W V . -
Signature 201-1000 Amp.Under 600 V � • 0 1 Ct Jr�
OOver 1000 Amp.or Over 6QD V _
Exemption for Reg.Moinl.Elec�. • • • t ( �,�,.J
SINGIE FAMILY Temp.Power Pole 8 Appurtenances
NOME OWNER-BUIIDER�ECL4RATION Sign with One Bronch Circo�t ��4��-C%,7
I hereby offirm ihof I am ezempt from Ihe Confrodor i License pddilionol Sign Bronch Circuih
Law for 1he tollowing reoson(Seclion 7031.5, Business ond
Grofessions Code): �
� I,os owner oF the o ert Misc.Conduils 8 Conducfors
pr p y,will do the work and the
ttructure is not intended or offered tor sale(Section Olher(See Complefe Fee Schedule)_ ,
_ 70d4,Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby aifirm�haf there is a construclion lending ogency for
the performance of the work tor whith lhis permit is izsoed pERMIT FEE (Sub•Tolal) 6
(Set.3097,Civ.C.).
PtAN CHECKING FEE
tender's Name �
PERMIT ISSUING FEE
lender'S Address
I certify Ihot I have read this oppli<otion and state thal the TOTAI PEE .
obove information is corred.1 agree fo comply wi�h oll Coun�y
ordinances and Stole I s re aling Elecfrical wiring,ond
hereb a +horize repr o' es f this Coonty io enier upon � � �
th o -meMione ry f inspection p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignolure o Permit ee Da1e
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