HomeMy WebLinkAbout0756A (4) � WORKERS'COMPENSAYIDN DECLARATION. . �6� ����� .APPlI�EtfION�OR GL�C I R�.CA��P�RMIT � � � I herebg aff�rm�tbo��l hava a�certificate of consen!ro selF .�CE-806f , ' . insurm,or a certifrmta of Worken'Compensaho�Inaurance, 1 i �OUNTY OF� O$ANG�LES BUILDING AND SAFETY PoLc.ernfiedcop�f(See.3 ) : � . . . .. � . . . . . o r o C , b.�. � ❑ y� _, Company � FOR APPLICA�,"�TO FItL IN�. JOB ' , � �anifled aopy Is heraby.fumtshed.�. . � New Residenpal Bidgs..&Poala EACN. td0, ..� FEE ,. � AooaES5 � { . . . 1 8 Z Famil �FR S —� 3 �� L O C A L I T Y: Cerfifiad copy ia filed:�wl tbe aoumy ifding inapea- Y 59 tion.deportmenr. � � Mult�fomily Sq Ft.�� 'NEARE . . � �,�,�,��C� Reside�flar Swimming PooPe �� CROSS Si' � � dqtel.J u�_APplim� �.. OWNEROR� �t �, . i � � . - FIRM NAME - � . CERTIfICATE�OF EXEMPTION FRO �vJ ERS''- � � �� � �-nMJL ��� �` � � ��'���� COMPEN5ATION INSURANCQ ' �, . � � �Outleh:_Rec_Lighl�Sw:�. _ ... � qDDRESS ' - � � - � � � b�s-�dcflon naad hof b�tom b}ed tf 1h�work inrolved b � ��. Fint 2f1�.� ....,. �' ...�� C� P P Y n. - Additionai .. .. . � � .� .CITY �.."... _�., .. Tel:N � ' � 'h er'Ormtf'I�for ono hundrod dofton(5100)or�tas�.)� , � P Tolnt N, �N�£� .-_ . . fy thal in tRe�performance�of-the�work forwhich lhis . . .. �- . . . . ' �. � " �� ApPLICAN7. ... . .... .� .. , � . parmit is issued,I shal not employ any panon in any m er ��� htin Pixtures �- First 20� � ADDRESS � � � � so aa�o-be�ome sob t to the Workers'CO7nPens lows. 9 9 , � -� � � ; -�,�'.� � -� Addii�onaV Dotal.. .���PPlicant . TolalNy. . . � CITY - :4eI,No.. - � � � �NOTIC��TO�APPLItRNT: ff,�ofrar making�thin Cer�ificate of� � Fized Appliances Not.4ver t HP .� peRM�i . I �� � Enemptian, you.should becoms� svfijed��ra�tha��Workars' ,.��. �. Range�'_,..�_Heater�_D.W..r.�� APPUCnN � ' . � �Compensaflon provisions�of the tabor Coda,�you mwt��forth- � Oven ,..;_Oryer.�_.:.W.M.._�. � � �� ADDRES � - - � � with qomply wRh such,provisionr.o��this parmit ahqB be��� � Top ..T..FAU �—W H.._.� � � deemed revoked. � � � - ���� Hood � . ...,_ . ._. . . ...�. `..� CITY .� . . Tei.No �� j � LICENSEQ.CONTRACTORS DECLARA710N �> � �'"�"F�� ��he�'—' � � �ucErv o � . �..r"� �� � Oisp. �.,_,.:Room Air Cond —� REG.NUMBEA�� ..-..... . Class � �. 1 here6y affirm that}am licensed onder provisions of Chapfer A � , . . . - �i . . � � � DISTRICT NO. PROCESS BY i o�d Prbfessions Code�,arnd my license is in,full forte and effecf. �otus 8 6arga Applioncei - � . . ?� , Ucensq Number�� �������Qu , pe HP,KW,KVA,or KVAR � �� �� �. � � I � �.3���� �., .� . Po5 ze&T'.. .... . , .. . . ...._ .. FINAL . _.. .. ., ` y , commena wit edion Z o rvislon o t e uainau _ � � ,`��'�� � Up to f Incl. I r"i� � y,,,�1 ... .,� .�W y� .. � DATE �9 ,� �VALIDATION � j �� Comra'at� . - rl�� Date �'C� Over.i to 101nd _,. 3� Y Over 10 ro 50 Ind.� ' ��� � r �3 ;� Q , . . . -__^- . .. fINAI . . , lam axempt under Sea� ���-� . Over 50 to�lOq lnc.. BY � j 'i � B.SP.G.�for thia reason .Ddte•. ...' �Sarvlces;5��, ��.�er 100 .- ; . •. .. ... . . � z.,..� ----Y-. ; " � . . . - . � . ... wbd..MCC&Panalboards .'..' ..`. -.. � .. .. :.. .. . .-.' .- — . ' � 0•20(1 Amp.Under 600 V. �, , . . � . � . .. _ Signmura . . . . . ..�01'.�.tUC�O�Amp.Underd00V� . ._,..._._ _ ._.._ .__ .._ � ', . . _.. . . .._. � ', Ei . . � : � � Over 1000 AmP.or Ove�600 V..� ... ' � .. . �� . � . . ���.. i � � �Cemption for Reg.Maint.Elect . �� � .;,. . , .. _� . �_... .. . . .. `,... .... ... ..-. .�.. . .,. �. . . , �� . � - 51NGtE FAMILY��. .���..� . �SB n wBh qr Pole&.Appur�enanaee. . •. . � � .. � ��. � ' HOME OWNER-BUILDER DECIARATION � P� � �� � ' � ��� � ��� " �� � ,- 9 ne BranckGreuil . - . ; . . 1 harebp affirm thar I om axampt from the Contracror'a License � Mix.CondSign Bronch C�rcuib � � '�� _ �.. �. ' tMe following reoson(Section 7031.5,Bosiness and . � � - �� ��. . �� � I � low fo�ons Codm�: . . ,- . . Addit�onal . . . , ... bits ffi Gonducrws . �.. .-. . `. ... ... .. .._.. _a . i ❑egs�a s owner of ihe properry,.will do the wark and the • �Other(See.Comple)e Fee Schedule}_ � � � �O 7�b � suucwro h not inrended or offered for sale(Secrion . . __ . � .._ ,..,. _. ... . , � 7 44 Business and Professio�:Code) � � � � ��� � �-�� � �. � ����� ��� SxP3097,C vOCSTRUQION LENDING AGEN�9�9 �'/ .�. ., ... _ ..: (Sub�Totol) � _ . :�.. ,.._.. . . . . I • •P T�S O ....�. � �.a� 1 hereb off rm tha�ihore s a constroction lend n a en fnr i rhe erfprmance of the work for whic fhis rmN.ia isaued � PERMIT FEE ' , . ( � � . . - . . � � - � i ;r . ;, . . - � � . ...�. PLANCHECKWGfEE.... � :...._ . . `_... ., � . �.�. � � ._ ...... , _ . . � J � . . 'Name � . . , , . / � . __._.. � . . f ' � Lender's� . . : . . . .';' PERMRISSUWC.FEE.- . .�.� ... . . /D�. D . .. . .� ..� .� . . . ' Y��Addreu . � ., ... . , . . � '' ����i certif thot I have read Ihia oQplicatio�and state.that the � �rTpTA4 pE6+�,.�; . ..: � � ., :....: '���� - � � � . oboveriniormafion is correcl..l ayree�o comply wirh al!CouNy y � . � � � �� � ���� x � � � �# 2S,sa� � ordinances and Sra�e laws ragolatfng Elecirical wiring,arrcl . � ' � �� p . � 9 . hereby authorize rm esentatives of thts County fo enter upa� . � � � ��"� ' �'�� �tJ � � -�� `" .. " . �0�� �'"�� � :� � ; e ove-meNio .propertylor.inspecfionpurposes; ' �.� ' �� � .� . '� . 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