HomeMy WebLinkAbout1729A � - WORKERS'COMPENSATION�ECIARATION 76A663 �0.�81 qpp«CATiQN FOR ELE�'Rf��CA;.L P
� �I hereby offirm that I hove a certifimte of consent to self CE-eC6G
.e,or a cerrfica+e oi wa�ke.s Compe�soro���sora��e, CpUNTY OF LCS ANl'�ElES BUILDING AND SAFETV
� ��o,jj�o) ce+�i1 fled`�co y(j)� (�ejp 4{5 3900 Lob.C.
� p����y'O `�`�'! •� ��j C)U .��� FO�APHICANTTOFk11N JOb �
� Y �"Y �-1� i al l�
� �Certified<apy is here6y furnished. New ResideMial Bldgs.8 Pools EACH NO. FEE AOURE55�
Certified mpy is filed with the cooNy il ' g///"'�spec- 1 8 ZFomily,Sq.fL $ _ $ LOCALITY '� �ar-1
t on depar meni �� Muiti-family Sq.Fm.' g NEAREST
Date �'q �i . _ Residential Swim n Pools OwnleR Oa
PP FIRM NAME I^ r . � �
CE I 1CATE OF E%€MPT ROA4 WORKERS' Outlels:Rec:light�Sw._ N'A��
COM�ENSATI RkNE6 ADDRf55 �� (� �J
lhis s�etion nwd mF he aa Nad if fM work involved First 20
� ^'� � Toral No.—_ Add�tional CITY � m ` Tel.No.��,�--��$'
x�.p.mm f.le.ow.mma..d�►lers(tiw)e.�....)
I certify that in the pe`formance�of the work for which this A�`CHeCK
pe
permit Is Iss�ed,I shall nof employ ony p�rsen in ony m
so as to become subjecr io�he VJorkers'Compensation Lomsr Lighting Flzture<_ Firsr 20 AD�RESS
� Total No. Additional CIT � .
Date Applicanr � Fised Appliances Not Over I HP RMIi
NOTICE TO APFLICANT: If, afrer making this Certificate of ApPUCANi � Qr �
Exemption, you shauld become su6jecl fo the Wwkers' Range_Heorer_�.W._
Compensatian provislons of the Labo�Code,you must turth- Ove� _Dryer ._..W.M.— ADDRESS �� ��
wi�h comply with wch pro�isions or ehis permit shall 6e Top ,FAU —W.H.� CITY�`��� Tal.No.
deemed ievoked. Hood _Fan _Other—
LICENS€D CONTRACTORS DECLARATION IICENSE OR
I hereby affirm that I am licensed under provisions of Chop�cr 9 Oisp. _Roam Air Cond. -�. ReG.NUMBER ��S� Class.c,•"
�commencing with Section 700@)of Divisian 3 of the Business Fower Apparafus 8 Large Appliances DISTRIQ NO. PROCESSfD BY �.
and Professions Code,ond m license is in full force ond effect. ^
Y Slze d Type HP,KW,KVA,or KVAR �-v n' d
License Number Cc Class ��FINAL V
up,o i i�d.
- " � , r`�� �VOver 1 ro 101nc1. DATE � VAUDATIOH �
Convocrar � �� Q�e � Over 10 b 50 IncL � �
� � FINAI
I m zempt under Sec. Over 50 to 100 Inc gY �-'l.4-�.��� �
B,&P.C.fo�this reoson ^ Over 100 uc
� '�� 7l`�Ti �
Servic�,_",�}sd.,M,CC 8 Ponel6aords � � � �,P � e �
Dote: — (r0�_ 2��mp.Under 600 V
Signoture 2t31-1000 Amp.Under 600 V � � ��
� Over 1000 AmP.or Over(AD V ... ., _ _ "�
Exemption for Reg.Moln1.Elect. -,�,
SINGLE FAMILY Temp.Powor Pole 8 Appurtenoncas � ���
HOME OWNER-BUILDER DECIARATION �Sign with Dne&anch Clr<uit � "�y_��
!here6y offirm fhat I am exempf from ihe Contro<tor's License Addi�ional Sign Branch Cirwifs
Law for the follow�ing reason (Section 7031.5.Businses and 1 -
Professions Code): �J`� r��"��-� `��'u�GL�
❑ I,as owner of ihe property, ill do ihe wark and ihe M�isc.Condu'ds 8 Condudnrs
�--�.-r—._
struUure is no1 intended or oifered for sale (Srction Orher(5ee Complete fee Schedul=)_ .
7044,Business and Pro�essians Code).
CONSTRUCTION LENDWG AGENCY -
I hereby offirm Ihat Ihere is o constructlon lending agenty for
fhe performance of the work for which rhis permit is issued FERdr11T FEE (Su6-tolal) ��' �
�s�.soa�,c�.c.>.
PLAN CHECIfING FG#
Lendei s Name - S
PERMIT ISSUING FFE
Lender's Address ��
I certify fhat I hove read this applimtion and siate tooi the TOTAL FEE
abooe infermarion ia correcl.I ograe to co�mply Wdh all County
ordlnonces 1 Stqqq���e lows regulating Electrlml wiring,and
hereby auf o i�pre m tive o4 this County to eMer pon
ob - nt' edl�nspect�on �rpose� SB6 R6�i6RSE F�R EXPtANATORY LANGUkGE
ei� D
4 �� �� � + � � ���S
� � ' -� �� - � �a
- r OWMER-CtUILD€R�ECLARF,TION
APPR:IVA:S DATE` 51�1 T4�- �
1�� �y���E 1 herel�y affirm rh�t I a �mpr from ihc Cont.ocre�'s
License Law for rho following re s n (Scctl�n 7097-5,
UNDE:c5tA8 WORK 9usirtsss nr,d Professians Code):Any city or caunry wfilcli
ROUGH CONDUIT requirss o Fermtt ro conslrud,cfier,rmyrore.dc;noli.sh,
or ropxNr aRy vlrucfw�,prfer to 1ts ls.ur.nco, olso ro-
WiRiNG qufrrs fM app{ienM fw svoh p�rvr�it Ic f;!.v a si�,e�stutc�
FIXTUF'c5 . msnt 1(�aT iro!s lieertsed�wrorror�l ro llie provi:iotts of fhr,
Controcfos's Llesruse Law(CFr:,�n'e�S(commnncing with
POW�FR AUTHORIZED Sxtion 7A0@)oI Di«isien 3 a[fhe�s�n�ss ond Prol�s
slons Cod+J or thW he is exempt fnerei�om and�he bcsis
U71CIN CO.MO71F[O for tha a!lrged azemption. Any violalion of Ssnian
7031.5 by arty opp�i�oM�i�r o psrmit subjects fhn appli-
��� �wfsr on _ ront cant to a�ciNl perrally of nat mare thart fivo Mundred
� NorES dollars(SSfiRJ.:
❑1,oa awner of ihe pro�erty will do the work,ond
the strucfure is noi iNer,d.d or o`,fered for scJe.
(Sst.70M,Bdt7nrrs w�d Pro!essiort�Code: ihc GuMroc-
tor's l7cense!ow daes r,ei oF.-p;y to cn owr.cr of prcperry
whc Lw7?sh or lm�rroves fhereon, and wfio dces sucfr
^ werk hlmseN pFeWdwa tin�f si.�e7i improvemcnh cre nof
interrdx�or offered fur usle.If,hov�evcr,thc tui(din�or
�mprtx�s,n�nt!s so7d wiNNn onc yeor oI compleltcn,fhe
ownervbuUd�r wi!1 have ihe�urden cf prov�ng that hc did
nof 6utld or)mprove for the purFose ef scl�.)
t am axompt undcr Ssc. ,
8 8 P.C.for this roason
Dote
Owner ____��