HomeMy WebLinkAbout1624A (15) � � YdORKERS'COMAENSATION D[CtARATION � ' � 76q663 IUiel APPLiCATION FOR ELEC7RICAL PERMIT � �
I hereby rJfirm Ihnl I huve a cailificalv of consnni lo xelf .-CI:A(X�G
���so�c,o�a cr.�tilicatr,o(Workms'Conipensa�+on Insurancc, � COUNTY OF LOS ANGELES BUILDING AND SAFETY
or�a cerlifled ropy Ihereoi(Sec 3800,I.ab.C) � . .
P�ollcy Vo.__,_Compony__...—_.__._'. __ FOR APPUCANT TO FLLL IN 1� /
Curtitied capy:s h�rPby i�rnished. New Rcsidenliol Bldys.R Pools FACH NO. �{{ ADDRE55 �_�p.+r,; . t,�.;
� Certifir.d mpy is Fifed�vith thn covnty buildirtg Inspec 1&2-Fnmily,Sq.Ff.__ — £ LOCALITY �i d, � e�
tion de�or�m�nt. Muhi-family Sq.Fl.____._ ^ _ .,_ �'�pREST
� fk055 S7.
Dole__—_..—__.._Applicanr_ _ Residentiol Swimmin�Pools �JVJNER OR
FIRMNA�blC Cpf���
CERTVFICAI'E OF f:XFN1PTION FROM WORKERS' � p�tle�s:Rer,;�..7_uyi,�_—sw._ "'^'�
COMPENSnTION INSl7RANCE noUkr55
f irst?0 �
(This seclion need not 6a compleled if 1ho work involved by T�trd No..�_— ndrfitionol �.5 ;� �J CIIY Tel.No.
fhe permit is for�one hundred dellars($100)or lesa.) - ----�—
1 ce iii thW in Ihc >aila�mnncc of ihe.work for wbir.h�i1is . PIAN CHECK
� Y l APPiIi:ANT
permif is issur.d,f shall no1 employ�ny person in nny rnanner I—'—`—�--`—"�"—" -
so as b�ba<omr,sul�jecl lo fhe Workars'Compunsatiou Lows. ` lic�htiny Fiulures Firsl 70 . . . _ ADDNE55 �
. . Additionnl . . _..--.
��'[[[��- �/ �./� Totnl t�o._.__ —� CIFY Tel.No.
Uute��.Applicant�el���.t��_� ' Fixed Applionces Not Over I HP PPHMu�� �`/
NOTI.' TO APPLICANf: If, nlicr mokiny Ihis Cer6tir,oic oi APPIICAN7 ♦fi.,,�� C,/ ��>� �
Fxemption, you should br.crome suLject fo iho Wnrkers' R(10(3P-_FIPUIL'�.__U.�N._�
Compensntion provisions nf Ihr fobor Codw,yov mus�fonh Oven —Dryet —W.M,— ADDRE55
—�+.�� � e,6
wilh comply vv'IFi sur.h provixions n� thn perm�i shall bc Top —FFlU _—W.H._._ A �',� 6 7�/
i
' deemr.d revoke.d. �!'`' Hc�� _, � CIIY 7c1. // �
. . . . Fran Oiher—_ ` L"+� _
� � LICENSfD CONTRl�CTORS UECLAHAT30N , ; — I iChNSF OR �
�Oisp. —Roo�n Air Cond. — '-- --..... - KE(i.NUN�EN�� U 1: Class{'^/ O
I herehy aifirm Ihat I�m lic.r.nsed under provisions oi Chnpier 9 _ � �
(commencin<�wi�h See!ion%00O)of Uivinion 3 of�he Business DISTRICT IdO. PROCESSF.O BY
oncl Professiops Code.nnri ir�.y liceusr:is in tull force and wlfe<:1. � '�'O`v�r Apparaius R Lar9e Appliunces . �� �
� Siiu 8�pc HP,KW,SVA,or KVAH '/ ',.1� _ p
� License Numb�r_ c°.���—_Lic.Clus,�"'�_�_ � _,�_ Uptn I Ind. '?�U� � � "4 fINAL �—� -- '— ` �
Cnnirocto r. . ! --..__ Ovur 1 ta IO lncl. — �A�F —_�—_.—_' VALIDATION O
i. J�:�. �---f� �,�o;,��?.:i, o�F��o r�,so i�,�i. h-
<..
.:,.,,,
_ ;.. ,
❑ �� y _....—,..- � �-- r-- r'iyni' . , <";. , u
i I arn eneiril�f under$uc._____•__ ' ..—..._.— Over SO.�o IW Inc. — _". .,. F7Y` � �� R
' 1 Ovc,1q0 $.— �i-..__;.'...% �� �n
'� f3.KP.C.for 7hre roaznn_..__—_�_ —....—.._ .. ._��._.__ �.
� dScrvir.es,Sw6d.,MCC 8'Panr,lhourdx , —_�� �
' —..-----.--..—.._o�,P.—•—•--- o zoo a�,��,.u„d�,�aoo v 1 1,i'Ul1 � ' .
s��„<,��,�__.—...—..— ----- � soi-i000 nn,p.u��d��sa�v ��.—�-....—..--
� ❑ t. Over 1000 Amp.or Over 600 V �. _ "
Exemp'ion for Rug.Muint.F.IorL �
SINGI E FAMI!V :lenq��.Power Pole 8 Appurle;nances I�
HOME OWNER BUILUFR DECLARATiON � j `-'� �'���4��
.,Sic�n with Onc Branch Cucuit
I Firreb ralfirm Ihal l nrn exem 1:roni Ihe Conlr�r�or's Lrrense •+ �
Lnw fo�the faliovnng r�oxon(Seclion 7031.5; Bosiness ond ' �Additinnol Sic�n Bronch Grcuiis �—... �_"__ #�° •' � '• 'r' ,
I
P�or�ss�o�,t�o.�.�: — I o 4(i 0
� I,os owner ot 1hc�fO�JOI�Y,\NIII CIO 1IlP,wurk and Ihr, �M;sc.Conduits 8 Condoclors �..�. '--
�� slroalur� rs no�intended or offerr,d for sol�(Sert on . �Otner(Sun C"oinplete Fer.Schedule)� ... . ., n .. �f.11.,(J l} +
� 70C4.Bueiness ond Prof�ssions(:ode�. "..�._—..._...—..—.. ..'_ _—. � '
� � CONSiRU(:TIUN LfNDI'JG AGENCY ----�—�—•�----- -- O�L L�!--'FS.�J
I LcrPby aHirm 1hn1 ificrr is u consiruUian fendiny a�en<y for '� E�
iFie performonre oF the wurk for whirh ihis pr,rniit is issur.cl � pERMiI FEF �Sub�Toinl) .�� �: �
(Sec.3097,Civ.C.J — �
PLAN CHECKING FFF. �
i��,dP:�n�����._----- �d --d ;
. . PERMIT ISSUING FEE �
. Lende:'s Address—_.__—_.�_._._.— p
� 1 cur�dy Iho1 I hove.�cad ihis opphcaliun nnd sinte thnt thc TOTA;.FLf lc'�-d C�,.
�bove�nfonnalion is mrrect.I�qree lo comply wi�h all Counly �t
�vdvwncr.s and Sia�c Inws ror,�ulurinq Eleci�ir.ol wiriny.and ?.
hr.rr,by aulhori�e represenlahvPs ofihis Coui�ly lo r.nler upon
' fhe obove�rnr.nlionnd propnrty fo�inspeclion purooses. �„!
� SEE REVERSE FOR EXPLANATORY LANGUAGE _a,
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