HomeMy WebLinkAbout1036 S COGBURN LN (2) � �
WORKERS'COMPENSATION DECLARATION ��� 14�81 A�PLI�ATfO�++i F4R E�.�C i RICAL FcR�iii i �
1 hereby affirm itwt 1 have a certificate of consent to seif CE-B06G
insure,or a cer�ificate of Workers'Campensa�ion Insurance, COUNTY OF LOS ANGELES BUILDING ANO SAFE7Y
or a cert"rfiW�py656of(Sec.3B�W,�I�aT C���C� ��
1
P�ol'��v No. F Company FOR APPLICANT TO FILL IN �a8
Certlfied co s here6 furnished. ADORe55
PY' Y New Residentiai Bldgs.8 Pools EACH NO. FEE � _
� � Certified copy is filed wilh�the coonly boilding inspeo- �g 2-Fomily,Sq.Ft. 1695 5 — S LOCALITY �
tion deporfinent. Mulfi-family Sq.Ft �NEARE57
CRO55 ST.
� Residential Swimming Pools . �
� Da�e Applicant . OWNER O
� � FIRM NAME
� CERTIFICAIE OF EXEMPTION FROM WORKERS' Outlets:Rec�_Light�_Sw� ,]S 3, O ���
COMPENSATION INSURANCE � aODRE
Fint 2(1
(Thl�ieelion ns�d neT 6a eemploTed ii th�werk invelvad by Addirional ��T G 2668 Tel.N 8_
� Me parmit ie for one hundrcd dollars(3100)or less.) Tordl No.
i I certify tfiat in the performance of the work for which this q�N��pryTK
� parmil is issued,I sha�l no�employ a�y parson in any manner
so os�o become subject to the Workers'Compensation Laws. Lighfing fixtures First 20 AODRESS
Additiorwi
� Total No. CITY Tel.No.
� Date Applicanf - Fixed Appliances Not Over 1 HP PERMIT
�ICE TO APPUCANT: If, oNer making ihis Certifimte of ncrucnNr .V�CTOR ��ECTRTC INC.
�nption, you should become subject to the Workers' Range_Heo�er_D.W. — `1�
Compensolion provisians of ihe La6or Code,you musf forih- Oven _Dryer _W.M.— ADDRESSZ�LZ2 IG�SAS Ar`.�5� �
wdh comply with soch provisions or ihis permit shall be Top _FAU —W.H.—
deemed revoked. ��n RIVERSTDE CALIfb+•N��788-9110
� Hvod _Fan _Other_ —
LICENSED CONiRACTOR$DECLARATION LICENSE OR
I hereby affirm Ihpf I om licensed under provlsion5 of Chopter 9 Disp. —Room Air Cond. — REG.NUMBER Class.
� (commencing wi�h Section 7000)of Division 3 of the Business DISTRICT NO. . PROCESSED�
Power Apparolus&Lorge Appliances �
and Professions Code,and my license is in full force and effect �p 4
Size 8 Type HP,KW,KVA,or KVAR ; v
License Number�fC����3 Lic.Class �iQ Up fo 1 i�d. DATE �' �
� �L.EC'fR�CA� o�e,i,o io i��i. � l��;� � vnunnnon p
# ConTracfor Da�e Over 10 to 50 Incl. FINAL � U
❑ I am exempt under Sec Over 50 to 100 tno 8Y �� W
} Over 100 � .� � �
E 8.8P.C.for ihis reason - N
� Services,Swbd.,MCC$Panelboards � �� Z
Date: D-200 Amp.Under d00 V
� Signa�ure 201-1000 Amp.Uoder bDD V �
❑ Over 100D Amp.or Over 60p V
Ezamprion for Reg.Maim.Eled.
� SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Bronch Cirtuit
�by affi�m thai I am ezempt from the Contractor's License Additiona�Sign Branch Circuits �� 7�'� A
�,...%for the following reason(Sec�ion 7037.5,Busineu and
Professioni Code): �.'�• • • � �2
� Misc.Conduits 8 Conduttors
I,as owner of the property,will do the work and the - � • �E 1,3 0
structure is not intended or offered for sale (Section Other(See Comp�ete Fee Sched�le)_
7044,Business and Professions Code). � . • • r Ej�,�}Q czi
CONSTRUCTION LEN�iNG AGENCY Q�,z 7••8 U
I hereby affi�m Ihot ihere is o construction lending ogenty for -
Ihe performance of ihe work for which fhis permit is issued PERMIT FEE (Sub-?oral) 6]� Q � �
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
Lender's Name �
PERMIT�SSUING FEE IO � O -
Lender's Address 81 3Q
I certify thot I have read"tlqis applica�ion and state ihat the TOTAL PEE � �
above information is corroct I agree io comply wi�h all County �
ordinances and S�aie la egut ' g Electrical wiring,and _
here a��horize repr taii of�is ,nty Sa enter upon
ab ve-rrTeniioned pr�y or q ection pdrposes. SEE REVERSE POR EXPLANATORY LANGUAGE
�. � �
Signqture qf PermiNee Date �
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