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HomeMy WebLinkAbout1788A - � -� �.,�+:���-.�,:��`i�'�.� , '--,�.::,M.,,...���7'-� ��.. �^" ��- - :_ a:,� �����'''��.-�"��� � WORFCERS'COMP�N3AT(O�N D'ECLAR,4'�N 76Ase3 t0isie� /� '`d "� �' "��""'�"��""°�' ' � �I�hereby aftirm that I have a certificate of consent to self insure CE eo5G _ J�PP�lC�►TYO�i�C�SR �LECT��AL PERMIT� � � o a roeafiscate oi Wo�kers Compensation Irysurance;or a'certified COIINTY OF LCSS�ANGE�E$ BUILDING AND SAFETY � o Qthereof.(Sea 38Q00 La6ry/(�-':1 (�, � � !i . � �_�, ." - .� tj� ����, PoiCyTdofl�i�� +�COmPa�Wl�'�t'KO'^-'e - .. _ ' fORAPPJCANTT?f"�ILCIFr �.. � . JOB�W P�_�7 S. D+=��A�'J✓ q. !�' . . _� . . ' - �; .. AD�RESS Certifietl copy is hereoy furnishetl New Rzsiden'ial�Bitlgs�&�Puols �y � ��� NO R FEE : . -.. . .:... .... ..... . ,.... . . .. ._ -, _.�� -. .� ` �.:: . .. � .: . 7&.2-Famil .. . � . : , �LOCALI7Y - -� � �. -. Cer4hetl copy is-filea wrth tFie r,ounty 6uildmg mspection y:Sa Ft � $ — $ � .� ' �a__. �(� _�,__._,,,,,,� '-- depaftm nt �� ,. . Mul[i tnmily So R. — vEARE5T .. -� Uate f ,ypp����t � -R sidential�5�aimming Pools � � � - . eR�SS ST _., _, �,;,i,,�,,.y^ - - : � � obvNER Gp S���y., �!,�y 9 ,-. .�. � .,�..� .;�r-s �., "' . '� FIRM.hAME „_c4lr-Yy ��WK%iN SIZf� s�^ CERT(FfCATE OF EXEMP7f6N'��'OF.��ORKEHS �� �� Ou:lets.Rec�Light�S•„r� � ~ . � .���� .�. .j COMPENSATION INSURANCE �� � �� .. .I- • �qoDpESS „j � /=�-f�fjt�,,.,�1� - IThis section need not be completed.if the work��volved�by the � ,� ` Firsb20 � ' . , ..._ .. _ _ _. Tota�No.� 4 f�-qd�itiunal CITY . Tel;No. permd,is forone hundred.dollars{$1001 or less.)� � . ...�� � � . I�.Ceftify thdt in the performanCe,of the v✓ork fOr whiCh this pefmit , PLAN CHEC�( ". -. -- � IS�sued,f shall nOf eRiplOy aRy p2f501]In 211y rF12/1rtBf 90'23 S'G�� � � APPIICAN .<.., „�., �-- - � � '- become suh�ec[to the Workers CompensaLon Lawg., . Lighting Fixtwes fiist 20 � � ADDRESS- ��� �� - _. Addihonel � �� "` "". _"'�� -� � -� - - Total No� � ... �-� f . Date - Applicant - � .� � : `�. -" CITY TeI.No , . �.„ ��. Fixed Appliances Not Over 1 HP pERMiT �� �" ��¢ - a� N0710E TO.�APPL�CAN7: lf after making this Certificate of� • ,i 'r,.� Exemptron you shou�tl become sub�ect to ihe YJotkers'Compen�atan �Range�_Heater_�kV _ . - app�tCnNT k ��..� _.�l3�(;L I ��p� �-provis�ons of th�Labor Code.you musl forthwih�compiy vnth such .Oven_..Dryer_ Vv.M_,. I - � ADqRESS'�����5� ��� ,n-.� � pf9visions or ths Pzrmd shall be deemetl revo�c d.,P-� � _^.,::. .ToF ---.FAU ��.NlH._ .� .. - e17Y `:� ' � • LICE�ySED GONTRACTOR$'13FCLAf�iTION Hood_-fan�._ Othar_ . �} � � � ����� -Tel.No."�7�,�`- . _. . _....�-��. I hereby affirm�that I am.l�censed untlet prov s ons of,Chapter 9.. .Dis .��—Rocm Air Gore� i.ICENSE OR - . . (commenciitg w"th�SeCtion�70pC)of 6iVision 3 of the�&.s�peSs-and p —'� � ' - . REG:TU116ER- ���� `�Z. -.� CWgs.. Professions Code 2ntl my license is m f�'I torce and�effect � �. I, I olSmfG'Vo - aR0 ESS� Bv- _ ,_ ,. . Paxer APPara!us.d Lar9e Appiiances �� � � � � Sze 3 Type�HP KW,KVA,or KVAR 4' License Number `����' �' � . - .... ,y •�..-�' ��� �,._ .*�Uc Class� � ... .. .UP�c 1 Inci{�. � . �� PINAL . . .... . . U co�t��ror�`fit.i.'�'�4 A�l�f�Lt.i '7 oaer i to io��ci on� - � ..,Da[e � �� r�/ __.. . -. .. :,, .VALIDATION-,. '•-' O � --- � -�Over 10 to 50 Incl. ��-� -�� ❑ I am exempt under Sec _. ..,_.:. T �..,_<,;,.. _ , Oyer 50 to 100 Inc �.. gy AL - � 6&PC.-for this reason . ��. -,--.� - Over 100 - .. �. - N �_ .. � -� �-�� �Sernces.Swbd.:MCC&�anelboards �� � � -- � � . - � --� � � � - - ��Date. . � 0-�200 Am�.Under 6Q0 V � �^ - Signature, - �--- •�-�. ���:�+^�:��K'�.''�� � 201=�OQQ.kmp Uncer�600 V.� �' � � � � �- - . . .;-- �� . .... .�. .. . ._ . . . �"`-�"'- Over 10CD Amp o!Over 6Go V � � Exemptbn for Rec:-Mami Elect��� - . . .. . .. . . . .. . . . _ _ ' " - , � . �..< . -�-- _ . . . . _ . - - SfNG�E fAMILV�� ., ., �: Temp.Power Pole&Appurtemnces � � ' HOMEbWNER-BUILUEF7C}�CL'ARATION - Sign�wrthOneBranchGircuit �� � � - �- - - � � - .1 hereby affirm that t.am�xempt from the Gontr2cWrs License�aw .-. � � . -�� - - .q .tor the iollowing reason(Section 703 i.5:8usmess znd.Professrons -- Add.itional Sign Brancn.Circcits . . __� .. "� 7��,-s A -�Code)' . .. . � . . ... . . . . ... . ... . . . . ?.}�o�e�e a i� . . ❑ i,as"owner of fhe�properry,will do the worK�and the st�uctur2 Misc Conduits&_Conductors �. � _ � � � . � . is not intenfJed or_Ufered for sale(Sect�or,�7044 6usiness Other(See Complete Fee Schetlule)_ . , ! a e`Z�..7 5 and Professions Code) � " - ��� ,-��a.,.�...��- � � - � � - . - � � ..... ...,. ... �� eeG-Q7�Jo- . ... . , _._, . . -� - F, _. - -_ _��.:..�_ _ . ...-�x_ �rze � - GONSTRUC'fION L�NDING AGENCY -- - � - �� � -� - � . . . �.O 4.i..:,.y�.7.. �I-hereby affirm thet,there is a conStruction lendmg agency for tha � --" _ . � � � .n:--�. ... � _�..... ��.. . -�performance_of the�work tor-which this�permit is-issuetl i5ea 3Q97 - pERMfT`FEE"� - � - (Suh-Totap -� ��_ . . . .Civ.C.L � � � � , � ���� ' � � � � PLAN CNECKiNG FEE -.�..- -. . - s.�^,.,�.... N. ....<...:-- . ... . . . . .. . Lender's Name -- � _--�.��--w�- . � .., 9 .. ... - .. _. '�� -PERMIT ISS4ING-FEE . ._ ._- _.... .. . . .. � HI,:.� . _.. ._ Lender's ACtlress .- .,._�., .., k w ..., . . . � . . � Ycertify th�i�ihave read ihis applicatbn and.state that the a6ove- TOTAL FEE �-��� � _, _,. .- .... �-�C'" � _.._.,.. ._�„�.. .. - .. ....__._._._ -,.. . . ��.infermahon is correct.Tagree to comply with all County ordmances . . ,�.- . . . .. . . .�. � - .: - - .. . and State laws regulahn9 Electr�cal �einng antl nereby authorize . � _, ,. ��` � - _ .- _. �.w � :. reprasentati�res of this County to eniel upon[he�bove menlloned . � ., - - ���,��..�,�,4.�,��,-,�,,ay, _ � „ ___ � , _: pioperty for inspectiop purposes " �- " -" -- ., -_ .�:�.; ,r�, -.��-,� � ' �,q�� ... . . . .... SEE REVEFi$�Fb���'�CP�I�lATO��IANGUAG� . . . . `� G��a �i--i I- �J . Signa�-`�e�of�ermttee � Date . .-: .. !' _`. �` �: - -. _ � ,:�. . _ -... . - _ �- - , . ..�. :: -� , -� . f.; .�: �. . . .. v�M .�, t_.Ew x.��� _ -: - -- - �u...-�.-,.� -� - .s.-.,..,.�.m. � .. 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