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HomeMy WebLinkAbout1288A WORKERS'COMPENSA710N DECLARATION 76A663 10/BI qpp��CATIQN �FOR ELECTRICAL PERMIT � I hereby affirm that I ho�e a certificate of mnsent�o seff �E-B06G � s��e,o�a certificare of Workers'Compensafian�nsurance, COUNTY OF LOS ANGElES BUILDING AND SAFETY fied�cofp ihereof(Sec 3800,Lab.C. ��� `� Compony FOR APPUCANT TO flLt IN �Qg S /� 1 S Ce�tified co 5 hereb fomisMed. EACH NO. FEE A��RE55 Pv' Y New Residential Bldgs.&P ol a ; _ § � � � Certified copy is filed wi�h rha counry building inspec- 1 8 2-Family,Sq.R. LOCAUTY Qti�,7 de rtment. ,/; MuHi-family Sq.Ft. — NEAREST :.r»,�.;�. ]/� r���m�� Residenfiol Swimming Pools CRO55 ST, Dale.7/��Applicanl � OWNER OR FIRM NAME N CI CER7IFICATE OF EXEMPTION FROM WORKERS' MAi� a' � � � Outle�s:Rec_Light�Sw.^ COMPENSATION INSURANCE Firtr 2D Aooaess (This s�cffon nsed not b�eompletad if ths work Irtvolv�d by To�al No. CITY Tel.No. � ths parmif is for ona hundrsd dollan(S1D0)or Issc.) Additional VLAN CHECK I cartify/ha�in ihe performance of Ihe work fo�which this APPIICANT permil is issued,I shall nol employ any persan in any manner - so as to 6ecome subject 10 ihe Workers'Compensation Laws. Ll9hting Fixfores Firsf 20 ADDRESS iotal No. Addirional /"�� CITY Tal.No. Applicant Fixed Applian[es Naf Over 1 HP PERMiT %� NUiICE TO APPLICANT: If, after making this Certifica�e of APP���NT r L' — � Exemption, you should become subject to the Workers' Ronge_Heatar_,D.W._ Compensatian provisions af the Labor Code,you musi for�h- Oven _Dryer _W.M.� ADDRE55 Q / with comply with such provisions or rhis permit shall be Top _FAU _W.H._ deemed revoked. CIN� Tel.No. �ICENSED CONTRACTORS DECIARATION Hood _Fon _Olher_ � UCENSE at p 2 /yr >fi I hereby affi�m ihal I am licensed under provisions of Chapfer 9 Disp. _Room Air Cond. � REC�.NUMBER 6c,,,;J Closs�,.—/L/ � (tommencing with Section 7000)of Division 3 of ihe Business DISTRICT NO. PROCESSED BY n-. Power Apparotus 8 Lorge Applipnces and Professions Code,and my license is in full force and effecl. /w U �n ar. /i,�,i1� Size 8 Type HP,KW,KVA,or KVAR� v�J License Number G�L� Lic.Class �' �� Up�0 1 Incl. � FINAL ��1�.�,.Ty� Q'^,.��. Over 1 to 101nc1. DATE f�/li��d ALIDATION � � Contracto �!!2'Sd/� Date� O�er 10 to 50 Ind. � OFINAI 0 I am exempt under Sec. Over 50 to 100 Inc, BY N B.&P.C.for ihis reason �°e��� z Do�e: Services,Swbd.,MCC$Panelboards ► � 0-200 Amp.Under 600 V Signature Z01-1000 Amp.Under 600 V � Over 1000 Amp.o�Over 6W V � Exemption for Reg.Main�.Elect. " SINGLE fAMILY Temp.Power Pole 8 Appurtenances :'� 2 Fi.H{I HOME OWNER-BUIIDER DECLARATION Sign witb One Bronch Cirtuii �� I hereby affirm tho�I om exempl from�ha Contracloi s License Additional Sign 8ranth Circuits #`� � ' � �2 Law for the following reason (Section 7031.5, Business and Professions Code): I^ U 6 6 8 6 ❑ I,as owner of ihe property,will do the work and ihe Misc.Conduits 8 Conductors strovure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ , °� `" *'��.:.6� 7044,Business and Professions Code). O E'�,2 S"�6 � CONSTRUCTION LENDING AGENCY I here6y affirm Ihaf Ihere is a cons�ruction lending agency for � rhe performance of tbe work for which this permit is issued PERMIT FEE (Sub-Total) (Sec.3097,Civ.C.). � PIAN CHECKING FEE Lender's Name Q PERMIT ISSUING FEE � Lender's Address � � I certify that I hove read this applicalion and stafe tha�Ihe TOTAL FEE above informatian is correcL I agree fo comply with oll County - ordinances and State lows regula�ing Elecfriwl w ing,and hereby authorize representatives of this Couny ta enter upon e obove-mentioned property for insped�on p rpos . SEE REVERSE FOR EXPLANATpRY LANGUAGE � � � Signature of Germiuee Dale . . . � .� . � ' � ' k; �p'J� �; .�`,!l � � �` Ac� .�VA 5 CSATE �' 'a . _ .. . s�£iW�I�R-BUILDE2 DFCLRR'iAT(ON �- �.. - . � I � S C7�kTt:Mf.� � , . T[Mp PO�ER i �f.��—��LL E �w . . � hsrr.fay�{*irm that I . .xr.npt from tF,e C .^tractor'e � - - �--�— ---— ` �� - � Licenaa ! .4� for ihe fo lo iny r eson iSrrt on T03I.S. �� � UW€�$ik��J0 !: - � £�stnwss ar,�P�afessia»s C�de):Any c�fy ar ceVnfy wh/'t�r � . _��_�.._..__—�—�.—.�_{ � , , . . . P,OI,�G:i C^kDt).' '� ra�.�iras a�F'!t1;�4 to.conRtruct.olter irrisxove.demolish. �� or Yappir�opy 5lrucfwe,prlar fo fts hsucrtco,�v�so rP- ' -� � � �... ..-�.� _.�_.-.__ '' . � � - � � � �YIRINC . � qutros fhe vpsplicant forsuch permlt fo file o s/gnad stofe- ment thof ha Is�t�cwnseef pe;raueni to tha pravla7qns of fha . . � �FEXiURf;' - �� ��_ _ V �_ . , Controcior's Ltc�nso Lesv(Chapfer 9{comroonc'rng w)ih . ' - � Ps��,H'EP,AUTN�YIZEG � �M . � Secrian 7QtlOj of DtvisrQ,�3 af the Bu:tness and P!atas�� � s�ons Cade)or tt��f 7ie Ia eaempt thorofrom and tho bns7s UTitl'Y CO N �T3PIF.i F� _� ____�� for fhu a(leg�d exsmp7ion Any vlola#ion of.Snctlon � � --... . __._._. . . ����.5�Y wTY�FPltca.�f far n permri subjeets�ha appt�- F3NA` �,�fQ'`"'^`.,�ra�f_ -- . . . cc�t io¢c7vi1 p_^ao!ty of nat mara thon fivo bun�'nd ' !�OTES . � dotlars(ffiSflC).: - . . � , � . . . � � ❑I,on cumer of tha propc,aty wil!da the work.,nd � �� - � ..,_ _,_,,,,, ,._, thc s�ruc.tur�is net in�end,d or pfier�d foi sale. � � - � . fSer.7Qqi,'�:usine=_s and Professions Codm: Fhe Contrac __'._._— ..�.�`�_...._.�._.�-__.: `...._..t.e.� -� �-��,�„�_____ lar�Litcr.s�Ccvr davs naf aFpiy to an owner o{properly .. - ' � wi�a bu,lds or�fmprovo: 1he;eon, and who does svch � ' � � ' � � - � - - �v�rk h7ms�lf provldnd ihct such Improv2monts arg not _._..____=.-.:__.______.._____'._____�__ -_. �._. � _T. �._. . .. . " . . -. .. � � infa=ndsd nr otfnred for sa1e.!f,howsver,the bvilding or :._..._.____.�__�___ _— _�_ tm�r�avc�m ani is said w?tFfn one yocr o4 complefion,Ihe . � � ovr�er-kru!idar w.t,h�ue the b�rd�n a.'p-oving thct he d�d �.._.. --- ________.__---�._..___. -r�n�Euttd or improvc for ths p�Rpcs.n bx sale.� . . . _. . ����t a?n;exr:mpt und�r Sac. . . , v.__� _���-----.__ _ �___.;,_____.�_� B t3 P.C.far this r�ason------. _�. --------e.__—..--- ---------- __��. - �,cie--- _ __._._ -- -- --_.. _.__----_.__.____...�.._.�._ _ . Ovmer.------"— -- "._.