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HomeMy WebLinkAbout0796A p�-�- �d , __ m� � /'j R _ WORKERSCOMPENSATIONDCCLARATION - 7sA6�3, 70/87 ,/�Df1a�.��ATrC}N.�"�!_�!'S �L�V-+�-���J�"!�_:I���,7,IT'.. -� � ���7.I I herzby-affirm that 1 have�a certificate of consent to self insure,�� - `.r � �R - ur a ce,ificate of N/orkers Cumuensation�nsurance,or a certified ^L4l1NTY-0F LOS iiNGELE$ � a� 'B�ILDIN��N�aS`A+�'ETl`� � �� � � copy thereof(Sea 3800,1ah C.) - - - - - � �°' 3��� } � . . . . .. . : . -..' � -. - ., .. r "ulicy No; ^� FOR APPLICANT T6 FICL 7N -"'� ���� � �� ��� ����� �-;r-i �i, � � ❑ .,�mGarY� _ . . _.,. H4�UNeas ?�l „i .J �r�, ,hc�m., g-�4..; . Gertlfletl copy is hereby furnished. � New Residenhal Bldgs.&Fbols EAGH NO.�FEE �'�� ( 1&2 Farrlity.SU.Ft. i•'' $ '— $ L�GAIITY .�`( ��_lI�.�l��Cl,,�C+.l� � 'Certified�copy is"filed�v✓ith the county bwlding inspection� NEAaEST � �e �� �-department. � � � -�. � � MWti-Family Sq Ft. cROS6sT. �L-�'d=��d-�"E"��"i'S � � '- � - Resitlential Svnmminy Pools -- pyvNER Ot� -. Date AppliCant FIaM N�ME ��� �''� t"'t���� ¢ - � 3 � ,�_..� '-�-CERTiFICATE-OF�EXEMPTiON�FROM�WORKERS': �AAiL � __ Outlets.Rec�Light!_Sw.7 � �j'" ��qDDAESS 1'�ta� t- �-iS�+}'� �=i-"�''^T�'" F��- -' �� � COMPENSATIONINSUFANGE �� Fi�Sk2U (Th'rs-section need.not 6e.completed�t the work involved by the. � GITY {_,;,!�r�#�}Ci'(' Tel.No.�cf°f-�,:S�i� ; Total No.� Adtlitiaiai y permit i&for.one hundred dollars.($100)or less.) - - PLf.N CHECK � ',1 certiiy ihat'in the-periormanCe-ofipthe work'{br.vJhich3hi3 permit � APPLICANT � =is issued,I shall-not•employ arry��persorrlra-any�manner..so as Yo � � � ' become cubject to.the Workers'Comoensation Lavos. . : 1_ighting�ixtures �ir;t 20 - �ADDRESS- � -� � , . � Additionul Tota(No.,�._ CI Y TeL No. Date Appllc�nt - � -� �� Fixed Appllances Not Over 1 HP ,ERMir , ^�� NOYICE TO APP i ANT: !f, �f-� meki�r�. his l.e;.et,i�� ��f � I ,ppp Ep�7 � �a� � �-Exempt�on,you should,become subject to the\Workcrs Cnm�ensation +. ��n�—Heater_fl W. ___ ` ! . � .provistors of N�e Labor Code,you m ist fortfiwith comply with auch - � Oven, Dryer� W M _ I I � A�DRESS f i -provisions or this Genn4�shaN�e de..rcwd�eve�cetl. Top _ FAU _ W.H � � � GTY —�� �I.Na. � IIGENSF��ONTPiAGTORB DE�LARATION� Nood..—Fan � Olh�� I —� . � it;ENSE OR 1 hereby aEfirm that I-am�icensed under provisiens oi Chapier� _. Ois _Room Av Cond - � Gass. � P� — - fiEG.NUMBER (commencing wlth Sect�on 7000)of�ivlsloq 3 oi the Business and . oi5T[ttCr No. Seo eY � Professions Code,and^�y ticense is i�i fW!force and afiert . pov,ryr Apparstus 8-Large Appllances ��' } �,—� � Size A Type-HP,KW,KVA,or KVAR �edL- ��"''� . � License Number Lia Class _lJp to 1 Ind. I 9NAL � Over 1 to 10 I�ic4. __ ( �� DAT[ �l"-rn t�\ VAIIDATION . 8 $ Contracto� � Oate Ovor i0 to 50 Incl. �F��A� ' � 6 ❑ 1 am exempt�nder Sec- Ovsr o�to}OO lna I gy Ri��G'� � B.&P.G#or this reason _ O�aer tU0 � � � Services,Swbd.,MCC&Panetboards ��� � � �_. Date:—.._ p-200 Amp.Under o0D V �� �:�:��(p,v r�. � � Signature 201-i.^,00 Pme.UnU=r 600 V #! s �� ,� .��� ❑ Ove+t00G Amp cr Over G00�J � � Gxcmption for Reg.Maint Elect. ��w e � a�i�: �� I S1PiCLE EAM1,�ILY Temp.Power PcAe&Appurtenances �I �.ffi g # �.r,;�-_ � 'HOME OWNER-BWLOER DEC�ARAYION - Sigia v�th One Sranch CirculY _ � � � { (here6y affirm thaf I am exemol from the Contractor's LiCPnas Law ��. qdditional Sign Sranch Circuits (?�y}?�?w�,Q"� � for the follawing reason(Section 7031.5,Qusiness and Proiessions �� # Goaei: � �jj' Misc.Conduits&Conductnrs �. - - . - �A1 �,as owner of the property,will d�the work antl the siruciure " is���t is�tencled�r offered for sale(Sectlon 7044,8i�su�ees.: Othcr f5ee Complete Fee Schedulel_ � and Professions Code). — � — �` _ .. � _� _. j CONSTRUCTION LENOING AGENCY :�� � - j I hereby affirm that therc is a conatruction lending 2gencV fo Uie . y--- � . . � � performance of the work ior�,�hlcli thls permit is issued(Sea 3D97,,. 3 pERMIT FEE (Sub-Total) � '�"�:�� i Civ.C.). � � � _ '3 - PLAN CHcCKING FEE- � � ��- � ; Lender's Name - �� � � % PERMIT 1SSUffJG FEE . � �- Lender's ArJdress � (�' i certify that 1 have read this application and state that the a'oove:- ToTAL FEE � � .. . .. _ __... information is correci.I agree to comply with all County ordinaness�` _. i and State laws regulc�ting Electrical wiring,antl hereby authorizP�-= . - _ .. � ' r rese atives of this County io enter upon thc above-mentroned i roperty or insb�eak(m posea � SEE�REVERSE FQR EXPIANASORY LANGUAGE � � - - ----� . o .�,z�, �`� . 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