HomeMy WebLinkAbout1147A � VJDRKERS'COMPENSATIONDECLARATION �6A663 10.�81 �,pp`f�qTION FOR ELE�TRICAL PERII�IT 6d
y I he�eby afflrm �hat I have a cerilficate of mnsent ta-�Plf CE-BObG �
- msure,or 7 ccr.lfica!e or wo�kers'ComnP�sa��on��surance, CpUNTY OF LOS ANGELES `� �Ly��r) BUILDING AND SAfETY �� � l�
"� ov o cestif�ed mpy thereof(Sec.380Q Lab.C.). . �[�= a3
j PolicY No. Company ___f____^" __FOR APPiICANT TO flLl IN ^OgKES� - .: �� y F s � 1 ��� �
g (""'� EACH NO.j
—.—_,—T .r.�
_ L_� Certified ropy Is nereby Tumished. New Residentiol Bldgs.&Pools ,_ , FEE . � '
��11 1 8 2-Famil S Ft. $ — S LOCALITY �� � � n
� �tion oed copy is fiied with the couniy building inspeo- 1'� q� • "" �""-'-
; � Certifepartmeni.� M�I1i-family Sy.Ft. ��'��__ —' 3 NEARFST
CRO55 ST.
J��� � Residentir�l Swimming 7000ls O'NNER OR
Date__—L=..z gApp�irant �'7�_e <TrJ� � FIRM NAME ' ,�� �� y � �
� CERTIFICATE OF EXEMPTION FRUM VJORKERS' � �^� � r y� ,�
CCh1PENSATION INSURFtNCE Ou. is:Rec_.Liyht__Sw.��� ApDRE55 �•Q, � '` ��
first 20 �� �
� (This section need not be eomple}ed if the work involved by Total No.� � CITY �1 y��, Tel.No. ,
the permit is for one fiundred do{lars{S�OQ)or less.) Additional
� I PLAN CHECK ,
I certif fha'in the formance of Phe work for which ihis '�-�� ��
� Y �e� � � �r.rr�i�a.rvi
perm�d is issued,I shall net eroploy ony person In ony manner
so as to become subject to the Workers'Compensation La�ms, Li9hting Fixtures First 20 i ADDRE55
� Date Applimni , pi R�A plian�ea er Ove��HP anal . .-- -i...--�- � j EP Mii '.6 .,`Tel.N� —Y � ..
I
NOTICE TO APPLILANT: If, after making Ihis Cerlifimre of � c�ICA��T Q ,?
Ex�mp'ion, you should 6ecor�e subject to ihe Worker-' 9�— � Y � 9�
Cempansotion provlsions of the LoborCode,vou must£orlh- O�oen _Dryer —Vd.M.— A�QRESS u r �
� with.comply with such.provisions or this p¢rmi' shall be Top _FAU —W.H.— � '��i. �, �
deemed��revoked. C!TY T1 Tei.No.��fi�'�y t�
Hood —Fan _Other— I---�_r1-1��! ln(SS 7 v2y'��R �-�.
LICENSE�CONTRACTOR$DECLARATION {LI�ENSE OR -
� Disp. _.ROGm A�r Cand — pEG.NUM6ER �� u1� ��ass. �,(CJ .
'hereby af{ m�ii�t I am I�cer.sed unde�}:m sions of Chapter 9 �— �
�_ lcomme.c ng wifh Sect�on 7000�of 6�v�sion 3 of_the Busine�s p N,p�Apnarotus&icrge A,�plinnc�s � DISTRICT NO. .PROCESSED 8Y �
� cnd Pr�fessiors Ccoe.ond my <ense s ir,foil iorr.e und effect. 1
Size 8 Type HP,KW,KVr1,or KVAR ; I �d �
License Nmnber ������ Lic.Closs �-�� U to I Ind- FINAL
P 3ATF �'x :�t�,,,-�y?. �
� f .�n P� ���5 ; Dver 1 to 101nc1. _ ��?p' .� VAtIDATION ^�y ..
Coniroctor �� Over 1C l0 50 Ind. �'
FINAL 4J
� I om exempi Vnder Sec �ver 50 10 700 Inc. � �BY �,�,,, � '
�
8.&P.C.for this reason _ Ove�100 ' - `»
! � � �
� �Services,Swbd.,MCC&Panelboards — .
�O1e� 0-2D0 2mp.Under 60Q V � �
SignaturP 201 -tiH70 Amp.Under 5D0 V
❑ Over 1(YJO Amp.or Over�600 V � �
� i
�- fxempi�on for Reg Mainf.Elect. �- � � �
� SWGLE FAMILY �;emp.Power Pole&Appurtenances � i � � �
�
HOME O�NNER-BUIIDER DECIARATION Sign with One Brarch Circuit �
' I hereby affirm th�t i am exempt from the Contrac�or's License .Additiona)Sign Branch Circuits " � � �' � �'
j La•,v for the f�llewiny reasan(Sectlon 70375, Business nnd � � � -
1 Professions Code�: -- � �`° � ��
❑ �Misc.Conduits 8 Conductors �
I,as owner o`the property,will dc the work ond the � ; o � � (�/' �
� sirutlure is not intended or offered for sols (Secfion 'Other(See Ccrmplele Pee Schedule)— ` .
� 7044,Bvs�ness and Professions Code1. -- f� a m �,/;�j�, -
�� CONSTRUCT!ON tENDING AGENCY �-�"'""-�"— �
�- I hereby offirm fhal}here is o mnstruction lending agency for � �'�J M��
� ihe performance of tne w�rk for wnich'his permit is iss��ed PERAAIT FEE (S�b-iot�lj 3� �
�. (Sec.3097,Civ.GJ. . - �
iPLAN CHKKING FEE -
� Lender's Name_ � PERMIT ISSUING FEE �� �� .. _ .. .
� Lender's Addross____ x
I cerrify thai I have read this applicaiion ond stofe ihot the TOTAI FEE !�
� abvve informa+ion Is mrreri.i agree to comnly w�th q!I Ccunty .
��� ordinances and State lows regulating Electriml wiring,and ._ . �
he:e6y a�thor�re representatives of th!s County Io enler ppon
1 c� (�
ihe obove-mentioned propert for inspec�ion purposes.
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