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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. � S8E REVERSE FOR EXPLANATORY LANGUAGE /{GC-�CE�L� /�-a�<-,d.,�r . �ignature of gir,�itiee D<�te � v � i . C rn -c9 �? � C�,7 x ' i . Z � a C . � � G� �� b . . ' � � � � � �'�" S zA.n -° v . 1,° u� � �` en ��, � z � � .f 1 • � � � O 7� � � �" x ^' � �, rt . � D . s3 ` (� �$ � _ `_; cs ,g � m � �� � C , � � ��N � , C'i) y �e�e+ � �C � � � ' . I S � 4 } � i � i ' i 1 i � M. � _ , � .Li O W � t� ? � � y� i,N S�!� � ,g� u� PJ fl �. � o �m �?y'0 3v, � Q ." 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