HomeMy WebLinkAbout1632A (9) W02KER5'CO�iPENSATIONDECLARATION �� ]6A663 � � ,�APPLICATION FOR ELECT�'�' �AL PERMIT � � �
' CE�BO6G(]-80)
�ne.�ny arr m m�i f nave a«nirce�e or c��.e�e m seir '- � COUNTY OF LOS ANGELES l , ��' BUILDING AND SAFETY � �
certificate ol Workers'ComDensatinn Insurance,or � ":I
a certified copy thereof(Sec.7800,Lab.C.). /� 1 ,
� , Pollc}sww�+wru$Q�mpan��4nil YYJ(�fIt11�IF ' FOR APPLICANT TO FILL IN ODRESS �E e
N2w Residentiel Bldgs.&Pools EACH NO. FEE
� Ce�iffieJ copy is hereby Nrnished. . 1&2-Family�5a•Ft.' $ — $ LOCALITV
Multi-family Sq.Ft. CRO55 ST IX���5 C
� der"tment PY�s filed with�he county Auilding InsDection � Residential Swimming Pools � � �
par I I 1l� . : � �IRMENAME
Datl.ra�lApO���an�„d,��`��� 'IaT: putlets:RPc.�li9ht_$W._ �6� ADDRESS
Firs[20
CtiRTIFICATE OF EXEA1PTiON FROM WORKF.RS' Total No.� Additional CITY Tel No. }
, COMPENSATIONINSURANCC ' ' vLAN CHECK . p ,
(ThiS uttiOtl�¢!d nOt hc a Pleled'�the wOtk I�Ivolved O APOLICANT U .
by the permit is for one hundred dollars(5100)ar less.) Lighs�ng Fix�ures Finc 20 ADORE55 ¢
� Tatal No.� Additional p
�1 cer�ify Ihat in the verformance of the work for which this. Fi.ed Appliences Not Over 1 HP � ci7v � rei No. U
�ermil is issued,I shall not em0�oy any person in any manner � PERMIT �y
o s to become subjecl to Ihe Workers'ComOensa�ion Laws. Range_Hearer_D.W._ � APPLICAN a -
' � � Oven_Orye�_W.M._ ADDRE55 N
Z .
Date Ap�iicant 7op _FAU _W.H._ . CITY�` TeINo.
Hood_Fan .—Other_ — ,
NOTICIi TO APPLICANT:If,efter making Ihis Certificate of pisp._Room Air Cond._ LICENSE
Exemption, you should becnme suM1jec[ to �he Workers' . . REG.Nl1MBER Cix� � '�
Compensallon�rnvisinns of the Labar Cod<,ynu must fo�th� Power Apparatu5&L3�ge APPliance3 - DISiRILT NO. PROCESSED BV �,
.deemed evoke�.�h such provisions or this permit shall be Size&Type HP,KW,KVA,ar KVAR !Q ' � ��i�,��, �
� ' UPi011nc1. . FINAL � I
� ' � O�r 1<0 7o inei. onre � � �� VALIDATION �
LICCNSF.D CONTRACTORS DECLARATION ' Over 10 m 50�Incl. . '
I hereb �ffirm thal I em licenaed under f Cha ter Over 50 m 10D Inc. FINAL � - � �
y a Provisions o p BY .
9(co cing with Sec�ion]000)ot Divislon 3 of Ihe Busi� Over 100 � . ��
nd Pmfessiom.Code,and my Iicense is in full force and � , . . '
effect. Serviees� � �.,
License Number��IQSq Lic.Class L'(� 0�200 Amp:Under 600 V , � ' '
'� r 207-1000 Amp.Under 600 V
Cantract��n���Nc���{p,�$ � I�I4 SrI' Over 1000 AmP.or Over 600 V '�
HOR1E OWNF.R�PUILDFR DECLARATION � . Temp.Power Pole&Appurttnanres ��6�Z A
I hereby offirm thet 1 a exemo�fmm the Conlrector's SignwithOneBranchCircuit ���� �2� r i j
License La�v for tne tollowing reason(Sec�ion 7031.5,flusi� Additional Sign Branch Cireuits � ,
�e„����,ofu.�o�,��ae,: _ r.••v.�o
' Misc.ConduNs&CnnAucton '
�I,as of ihe OroOerty,will do the work and ihe Other ISae ComPlete Fee Schedule�— , � •9.7�� '
siructure is no�Inlended or ofkred for sale(Sec�ion ••• '
ooaa,A�,��.,i a�a e.ore::�oo:code�. 0 2 2 3—8 2 i
CONSTRUCTION LfNU1NG AOENCY . '
I hereby affirm that[here i nstruction Iending ngency - .
fnr the performance ot�hegwo�k for which this permit 1s pEFM1T FEE. ISub-Toial). '
sued(Sec.309],Civ.CJ. .
Lender's Name ' P�AN CHECKING FEE IOne�Fourth Permit Feel �j � ' ��
Lender'sAddress PERMITiSSUINGFEE d � �
I rertify Ihat 1 have read this appllcallnn and ste�e that ihe TOTAL FEE ' . �
above information is correct.1 agree to comply�vi�h all Counly '� � � � ,
orAinances and Stale IaHs regulating EleciNcal w ing,and �r=���i jty7 . ' .
hereFy authoNze re0re5entativn oE this Counly[o en[er uoon y ,
ih aMove�menti ned pwperty for Ins0ecllon purpo5es. � SEF,'REVERSE iOR EXPLANATORY LANGUAGE ,
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