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HomeMy WebLinkAbout1029B 7874A .. _... , .. ,.. ., -. _ WORKERS'COMPENSATIONDECLARAiION � 76A663 IO�BI, � - �APPLI�NT�ON fQR��F�L��nICAL�"�ERMIIT ��� �' �' I hereby of{irm that I have a ce hficate of consent ro self CE-BDbG . i�sure or a�ert f�are of W rkers Compensalion�n ura�ce, COUNTY OF!OS ANGELES BUILDING AND SAFETY �� or o cer�f ed mpy ihereof Sec 3800,�1a6.C 1 . R M,�g.� �, �� ' -- �� ,�J �.imesiu«.:z �.-�n�.u'�$3�w_' ,:: �,.,.�, ' ��.:;�,..w�ar^;<,_... .. P❑ol<y No. �+!`� ompany-f'Ahl i�Lr70�,.F-7./s _ FOR�AGPLICAN7Y0 FftX�IN .. ,..._ JOB . . Ceriified Copy�s hereby furnished. New Residenfiol�Bldgs 8 PoolS EACH NO. FEE' � ADDRE55 9�a � � Certified copy is filed with the county building inspec- 1&2-Fomily,Sq.F1. $ — S LOCALIiY tion department. . . Mulri-family Sq.FL — NEARES7 � � � CRO55 5T. Date J�'Z��LApplican� Residenriol5wimming Pools OWNEROR � � FIRM NAME O CERTIPfCATE OF EXEhAPTId��FROM�VJORKERS' �� •j� ��` � MAII � Oudets:Rec Light_Sw. ,��4 � � COMPENSaTiON WSURaNGE Flrs�20 � d+.l � nooeesso� (This section need nof be complefed�F the work Invalved by 7ata�Ny,�� Addifiona� 9� Q'� CITY Tel.No. �he permif is for one hundred dollars(SI00)or less.) � I certify thp�in the performonce of the wo�k for which this PLAN CHECK � APPI,ICANT �ermit is issued,I sholl no�employ ony person in any manner Q sa as ta become su6jec�ta 1he Workers'Compenso7ion Laws. LighFlng Fixtu�re�s+Q, First 20 •�� Q �� ADORESS Y� ' - Totol No.'� Additional Dote A licant . CITY/�l�j Tel.No. ��.3`j .PP Pixed Appliances No7 Over 1 HP PERMIT NOTICE TO QiSPLICANT: If,�oher moking this Cerfifica�e of APPUCANT � ��j'T: �. � Exemption, you should betome subjed to �he Workers' Ranqe_Heater_D.W. ._ Compensation provisions of fhe Labor Code,you musi forth- Oven _Dryer �.W.M.� ADDRESS� $ � wifh <omply w'th such provisions or this permil sholl be Top �FAU —W.H.�- ^ deemed revoked. . CITY ou Tel.No7�y . . Hood _Fan _Other_ -- UCENSED CONTRALTORS��E�LAR�TIOPV�� ��� ,�p �;� � uCENSE Ox I hereby oftirm that I om Ilcensed under provisions of Chapier 9 Disp. �Room Air Cond. — REG.NUMBAR V Class. 1 } (commencing wiih Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY L�-� . ond Professions Code,and my Ilcense is in full force and effect. POWer Apparafus&Larqe Appliances �� � � � � Size&Type HP,KW,KVA,or KVAR �O Cv�(�}� License Number 37G7o4 ���.��ass � .- Up�0 1 Ind. PINAL � /�lce� ��.� S-'Z3-i�6 —�-- o9e�1�o 101nd. �ATE 1 � VALIDATION � Contractor pote Over 10 to 50 Ind. ❑ FINAL W I am exempt unde�Sec Ove�50 70 100 Inc BY ��� V 2,y� a � Over100 �n 8.&P.C.-for-ihisreason . ..-...� .-.: -�:'.s a o b j y G Services,Swbd.,MCC&Ponelboards � a%� �. � - - ���+ �ote: 0-200 Amp.Under 600 V �� '�� � n �;;y,7� Signatore ....--.-�.���--•�+*�*.�--*^..�+:.,rx-k. 201-1000 Amp.Under 600 V ie ..Q ....._... . ..�. .. . � Over 1pOp Amp.or Over 600 V � °�..�.r'�J`:'�v u Exemption for Reg.Mdint.Elect. i � � � SINGLE PAMILY . . Temp.Powe�Pole&Appurfenances �2�?���� HOME OWNER-BUILDER bE�CLARATION Slgn with One Branch Circuii I he�eby aHirm�ho�I pm exempt from fhe Caniractor's License Additional Sign Branch Clrcuits Low for�he following reason(Section 7031.5, Business and Professions Code): ❑ I,as awner of the erf II do ihe work and the Misc.Conduifs 8 Conductors � P��P y'w� � O er S�,e C m I � F e Schedule ► siructure is no� intended or offered for sale Section P )— 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY��� - �� 't` � �_78 t,4A '�.I here6y affirm that�here is a consVoction lending agency for ' - f� Ihe performonce of the work for which this permif is issued PERMIT FEE 15ub-io�ol) ���T,J a �c� e t e �� �(Sec.3097,Civ.C.). . . . ' � PLAN CHECKING FEE �� ���.�� .( '�,O S�V,C O Lender's Name - - - N PERMIT ISSUING FEE � i:J��i:.�J� Lender's Address - � �--�--yy,•••• �-- -� ���*'� I cenify fhat I hove read this application and state tho�ihe TOTAL FEE �j�`�' QQ, �'G,Z 5�'�q� abave informo�ion is correci.I ogree ro comply wifh all County . oroinances and Stpte lows reguldting Elecbicol wiring,ond „_.._ . , . - � � , . - ����- � hereby autharize representahves of fhis Co�nty to enter upon .. . -–� , , ... -., � � - the obove-mentioned propery�or inspection purposcs. � � � � � � �� � - .. ..y.., ..... .. .._�... ._. - „, ,-....��_..... SEE REVERSE fOR�EXPIANAT�Y LANGUAGE �-..�-�----� s—�3�!G Signature of 7zrmittee Daie � . .., _.._... :4.a.....,..,��-�'�. y. . . . .. . . . . .... ._. ._ . . . .�......_ �;, . . .. .. . ., � . i� ..,.... .. � .. a� _,..,.._ . . .. .. .. . .. . . . . . . ...,,__ �..___._-._.4.. . _..__... .. . . . . . - s i J R E� �! � . . -"I... .�.�:L i .�e:6 k��Z�."" , , . -.'vN��!.... F. 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