HomeMy WebLinkAbout1597A (15) WORKERS'COMPENSATION DECLARATION ��� ,0�81 qpp��CATION FOR EL�ECTRICAL PERMIT ����
aNirm tha�1 have a certifica�e of consent m self �E'� �
�r a certifko+e of Workers'Compe�sarion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAPETY��
:ified copy thereof($ec.3800,lab.C.) � �
!o. Compony fOR APKICAM TO flll IN JOB � O�O. n/yNO���� � �,
ADDRE55 a•,J
.;ertified copy is hereby fumished. � New Residenriol Bldgs.&Pools EaCtl NO. FEE �
:artified copy is filed with ihe county building inspec- 1 8 2-Fomily,$q.F�. S — S IOCALITY 4/f)�ONf, rf
lion deportmem. Multi-family Sq.Ft � — Ne.nREST � �y vey
. CR055 ST. �
Residentiol Swimming Pools �
qpp���p�� OwNER OR �
FIRMNAME ATh C.'VL'LO /Y�/L/
CERTIFICATE OF EXEMPTION FROM WORKERS' Oullets:Recy�light,�5w.��' , ' ��� ,�%L�i1/T/C L!/
� COMPENSATION INSURANCE a ADDRE55 3� Sn
��ecfion naed nof bs compler�d ti tM work inrolvad by � Firsl 20 n � � �
parmif f�for ona hundred dollars(5100)er I�s�.) To1a1 NO•' Additional ��TM/`lc.vTe,Fe /� ,Q Tel.No. _)YY0
PIAN CHECK
trtify ihal in the performonce of�lhe work forwhi[h Ihis . APPIICAM '
rmi�is iss�ed,I shall not employ any person in any mannar
�os to betome subject to the Workers'Compenwtion Laws. Li9hting FixWres First 40 ADDRESS -
p Total No. � Additional
otea o pplicont��F ELr�ci�c'ic CIN Tal.No.
Fized Appliances Not Over 1 HP PERMIT
IOTIC TO APPLICANT: {(, afler moking Ihis Cerfifi[ale of APFLIC4NT J-
:.emption, you should become subject to tha Workers' Range_Heater_D.W._ G'% /G
�ompensotion provisions oI Ihe Labor Code,you musl forih- Oven _Dryer _W.M. ADDRE55��f'�� p � / C�
wi�h compiy with such provisions or this permil shall be Top _FAV _W.H.�
�deemed revoked. � Hood _Fan _Orher— CITY �N�� ./� Tal: 3_�d�
� �LICENSED<ONTRACTORS DECLARATION Q(J UCENSE OR /� �
•I hereby offirm ihot I om licensed onder provisions of Chapler9 �Disp. _Room Air Cond. — REG.NUMBER � ,3 ��oSg• (..�/D
� (commenting with Secfion 7000)of Division 3 of Ihe Businest Powar Apporpt�s 8 Large Applionces DISTRICT NO. PROCESSE BY } .
� ond Professions Gode,ond my license is�n f�ll force ond eHecl. / 6 .
`�y�s � /I�� Size 8 ype HP.KW,KVA,or KVAR� ! � .cP�/ �
' license Number �Lia Class_Sr,_L_{L_ Up to 1 Ind. � d d FINAL - � - � V
Conlroctor nd'F FLeC%���Dare � b' � Over 1 to IOlnd. DATE C� a`��� __VAIICATION � 0�
❑ Over 10 to 50 Incl. FINAL I � ~
I om eaempt onder Sea Over 50 to 100 Inc.. BY. � ,- Q,�� �
. B.BP.C.for this reason �Ve��� ,' Z .
Daie: Servic MCC&Ponelboards ► -
:700 A nder 5W V
' Signature I Amp.Under 600 V � � .
❑ Over 1000 Amp.or Over 600 V �
Exemp�ion for Reg.Maint.�Eled. �
SINGLE FAMILY � Temp.Power Pole 8 App�rfenonces �
HOME OWNER-BUILDER DECLARATION Sign with One 8ronch Circuil �
I hereby affirm ihat I am exempt from the Con�rodor's license . qddiliona�Si_n Branch Circuih � ��5 9,7 A
lnw in��I,a{�II� ��e��,...�ce..i_..7Q?l.t,°V_...,,..,.�� , Q .
ProiessionsCode):/ �;� . • • �2
❑ I,oi owner of Ihe property,will do the work and Ihe Misa Conduits 8 Conductors �
struc�ure is nat in�ended or affered for sale(Section O�her(See Complete Fee Schedule)_ � � �6 3.2 5
7044,Business and Pro(essions Code). , � •V�L 5�
CONSTRUCTION LENDING AGENCY . - �Z� 7—8 4 -
I hereby affirm�hat there is a tonstruttion lending agency for
Ihe periormance of the work for which this permit is issued PERMIT FEE � � � ($ub-To�al) �� � -
(Sea 3097,Civ.C.J. - �
PIAN CHE�KING FEE
lender's Name�uH/r M/1 �f�� , '1 � � �
6 Y���C HN�� fJ.�'f't, v PERMIT ISSUING FEE O �U
Lender's Address GA'�f3L/'9A. C/�- � �" .
I certify ihot I have read Ihis appli�ian and s�a�e that the TOTAI FEE � � (,p'.�
above information is mrreU.I ogree to comply with all Covn�y ��
ordinances and State laws reguloting Eledrical wiring,and , . '
hereby aothorize represeMa�ives of Ihis Couny to enter upon � �� � � - � -
tl' obove-m 1 ne p per for tns �ion purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE
gnaWre of er itree / DaOte � � �
. . , . . � � i . . '
` . . .. • . . . �
' O z C � � � O C y .
-r ^ � _I A Z �
, . y r � '�A' N � � N � _
� O C n � � �D . �
-y � p � �
O 0 O � A �
� A � � � �
' �+ T � 7C m N .
. ' , � O
. �
. _ n
, �
0
, � , �
a
. �
� _ .
' i
N .
� � .
. Z �
D
-�
�
m
� , .
^
� . . /
' � . .! . � , ' .
O ° Go �3 � F� � o �-O o o °� w° ° n °o � � 10 �^�'
7 ID . ' O'� ti 7 �"C N!1 y �+ � , ! � � O p
� n x cv`aQ='cno� ❑wo �"Wn� o "� fiNum
. • - . , � oq� 3 0 3 a y �c'�a`Q-p 4 O o+ m�� " a,� .
. � . v � m� � °,N � m�o ° o� � ��°-oN-�'o o� � �� '
3 ti o, o �-w N o}.<.�m O���b� � �- - O
" N 7 oF_u�v3 � 0O � ..�� aST4`Q�� oo3 Z
0
. � � n. .� —oa<� aM - �a� ° bN $_c '� s m
. ' � ' - . O � � ,�.< 4 O m O N � � _„ . �Q m � -� m �• `�•C n '^ .0 � W .
� N O p � � CL< � fJ w �� O � � O _
o � � �, oa4> >-� `� �. 3 .;oqa'' m � � ea C
. , � � s�-3-o3-'" oro�o o .,,� � � Fa � uN 3 —
, , � �0 � �0° 3-oon-'o ° o`xw-�� na �no v
a co ..» �� o o ? "� ��'" T�'c °a�- k A
� -..C �b � �b 3 c'o o � �
� im �-$-�� •, ���� '0y� �b '� � �.`?.ao3 0
. . - . n �m ° ' o'Nm"�' o3�'c �-m � 300 �o� � .
� � � � m '�'^° °b ° � n m � o � < �' t°�o° ' U'`� ° �.
' °.� °,m` o a o ° °�' 3..N 'o'�,.�-.e°, 3 ,,. � o
� .. _ o °c o � m � � ° ° o �°��. 3 u 3� ° ��o r-•,,3 A
j S� �'' m O O i„ O C 0 O l Q S �
. . . . .. . G � � p 0 O -1 O S C u � j O O � N = � � � G .
. � `.�.oc'No$.o° f mYo2� � o� ° acQo Z
. ' $. o ' ombn o �-�'�-a�N � om> > >
�o a_3�
' �a=.r° � ^ � o . � °'v ^ o m F "� � N-F�'``�'o
- _ a� ° � �-� ^ a a'� M '^ 3-oo,' aTsi,�
+ .