HomeMy WebLinkAbout11_01_1989 - 2016 PEACEFUL HILLS RD � WORKERS'COMPENSATIONDECLARATION '20�19P°'���e� APPUCATION FOR ELEC ���0
I hereby affirm•,that I ha�e a certiticare of conseM to self [[Ag� ��
insure,�a cAriifi[ate of Workers'Compensotion Inwrance, �� � COUNTY OF LOS ANGELES DEPT.OF PUBLIC VV�� � l
or a certified copy thereof�Sec 3800,Lob.C. � ' -
i
PoliCy No. Company J FOR APPIICANT TO FILL IN JOB �/
�Cerlilied copy is hereby(urnished. � New Residential 81dgs.8 Pools EACH NO. FEE ADDRESS �
�Certified co is filed with the covnt bviidin ms ec- 1 8 2-Famil S Ft. S — S LOCALIN �
PY� Y 9� P Y, q.
tion deportmeM. Mull6fomily Sq.H, — NEAReSr ,��� �
�7�����C�� Residential Swimming Pools CROSS ST.
Dote � ApplicaM ,�3�ffi._,�'"�^'� . OwNER OR
� FIRM NAME �
CERTIFICATE OF EXEMPTION FROM WORKER$' � L pnqiL
Outlets:Rec� light Sw._
COMPENSATION INSURANCE / First 20 .S � AD�RESS -
(Thli t�ttion nNd not ba tomplehd if th�work Involved by 7mal No..S� Additional CITY Tel.No.
the parmit Is For on�hundnd dollars(j100)or less.) PLAN CHECK -
I tertify that in 7he performance of the work for which this . ICANT -
permit is iss�ed,I sholl not employ any person in any manner ��9hting Fixtures First 20 ADDRESS
- so as fo become subjett�o the Workeri Compensarion laws. —
Additional
�� Total No. CIN: Tel.No. � '
Date� Applicant Fixed Appliantes Not Over 1 HP pERMII
NOTICE TO APPLICANT: if, after making ihis Certifimte of APPLICATION G'
Exemplion, yoo-shoold become subjed to the Workers' Ronqe— Heater_D.W. _ .
Compensafion provisions of Ihe labor Code,yov mosl forth- Oven —Dryer —W.M._ A�DRES$ � � � � �� '
with comply with suth provisions oi this permit sha�l be Top —FAU —W.H.— �
deemed revoked. - � ❑T/�'/��/0 Tel.Noyr�� .
LICENSED CONTRACTORS DECLARATION Hood _ Fan �-01her_ '
Disp. _Room Air Cond. _ UCENSE OR 2 7 t'f loss�
I here6y affirm that I am liEensed under provisions oi Chap�er 9 REG.NUMBER /��J ��
(commencing with Setlion 7000)of Division 3 of the Business power Apporotus&Lorge Appltantes DISTRICT NO. PROCES BY �
and Professions Code,ond my Iicensa is(n full force ond effect. � �s O.
y� Size 8 Type HP,KW,KVA,or KVAR O
License Nomber r3 J//.1�7� Lic.Class - V
/7 r Up to 1 Incl. FINAL p �
Contrat���l/'�EY���^' . � � Over 1 to 101nd. DATE, J 3r �S VAUDATION �
g Over 10 to SO Intl. F-.
OFINAL � U
I am exempt onder Sea Over W to 100 Int. BY ,^ W
� Over 100 ��� a -
B.BP.C.for reason ► �
� Services,Swbd.,MCC 8 Paneiboards � - � � Z
. 0-200 Amp.Under 600 V ��7 7.5 A -
Signat �� 201-1000 Amp.Under 60p V #• • •.�:� .
OOver 1000 Amp,or Over 600 V � � - �� • •1 5 7 5
Ex on for Reg.Maint.Elect.
$INGIE FAMILY Temp.Power Pole 8 Appurtenances ' ' � x �
HOME OWNFR-BUILDER DECLARATION � • •b� �j,`]S ca
.. . -- - � -- � - Sign with One 8ranch Circuit- -..- . -.. -.--.. - . ..--. _. . .- . . - - . . --. - ._.-.
-I hereby affirm thot 1 om exemp�irom the Conrracror's LicenSe - .�2 r 9_$8
Law for the following reason(Setlion 7031.5,Basiness and Additional Sign Branch Circuits -
Professions Code): ��
❑I,os owner of Ihe properry,will do the work ond the Misc Conduits 8 Conducrors � �
sir�ct�re is not in�ended or ofiered for sale($ection 704d, Other(See Compiete Fee$chedule)_ ��
Bvsiness ond Pro(essions Code). �
CONSTRUCTION LENDING AGENCY • � .
I hereby aNirm that ihere is a constrvction lending agenry for -�
ihe performance of fhe wo�k for which this permit is issued PERMIT FEE (S�b-Totol) ,
(Set.3097,Civ.C.). , -
PIAN CHECKING PEE � �.
lender's Name - �
. . � PERMIT ISSUING FEE C7 �.
Lender's Address TOTAI FEE �� �S
I certify thot I have reod this opplicotion and stote fhat�he
obova information is torrect.I agree to comply with all County � �� -
ordinances ond Slote lows regulo�ing Elecrricol wiring,ond ' .
he authorize represe 'ves ot t ' County ro emer upon . ., .
t e ove•mentio ope r ection purpo s.
l /�� _ . SEE REYERSE FOR EXPLANATORY LANGUAGE
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