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HomeMy WebLinkAbout1147A (5) � VJDRKERS'COMPENSATIONDECLARATION �6A663 �O.BI qpp`f�qTION FOR ELE�TRICAL PERA111T 6d y I he�eby afflrm �hat I have a cerilficate of mnsent ta-�Plf CE-BObG � - msure,or 7 ccr.�fica!e�r wo�kers'ComnP�saiion��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 ��� � � � —.—_�._..T_' .r.� .. Certified ropy Is nereby lumished. g EACH NO.j FEE ' t New ResidenNal Bld s &Pools ._ � � r' ���111 1 8 2-Famil S Ft. $ — S LOCALITY �� � � n � � Certified copy is fiied with the couniy building inspeo- Y� q� ��y���— _; i NEAREST . � �tson depa tment.� M�Iti-family Sq.Ft- � CRO55 ST. �j>�� � Residentir�l Swimming ools O'NNER OR 'n Date__—�.L=:.z gApp�irant 3'7�� -��� � FIRM NAME ' ,e�� �� y � � � CERTIFICATE OF EXEMPTION FRUM VJORKERS' � � y� ��. CCh1PENSATION INSURFtNCE Ou. is:Rec_.Liyht__Sw.�� DDRE55 �•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 hundred 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 any person In ony manner so as to become subject to the Workers'Compensation La�ms, Li9hting Fixtures First 20 i ADDRE55 � Additianal . .-_-,-__.I_ � — 9. To'al No. I-�- � CITY Tel.No. Date Applimni Pixed Aqpliances Not Over 7 HP � j PE�:Mii � NOTICE TO APPLILANT: If, after making Ihis Certifimre of qip?I.ICA��T ,!� �-;? / 7 � � � Ex�mp'ion, you should 6ecorne subject to ihe Worker' Rpngv�Fleater_D.W. � -� � ��� Cempensotian provlsions of the LoborCode,vou must£orlh- O�oen _Dryer —W.M.— A�QRESS Y u r � � with.comply with such.provisions or this p¢rmi' shall be Top _FAU .—W.H.— � � deemed��evoked. C T� T1 TeL No.�� ��t�t� Hood —Fan _Other— �---"�'-r1-��/f ! ln�SS � v2°'��?' �- LICENSE�CONTRACTOR$DECLARATION {LIC.Et..SE OR - � Disp. _.ROGm A�r Cand — REG.NUM6ER �� u1� ��ass. �,(CJ . I hereby af{ m�nflt I am I�cer.sed unde�}xa sions of Chapter 9 �— � �_ l,comme.c ng wifh Sect�on 7000�of 6�v�sion 3 of_the Business p N,p�Apnqrotus&Lcrge A,�plinnces DISTRICT NO. .PROCESSED 8Y � cnd Pr�fessiors Ccoe.ond my�<ense s ir,foil iorr.e und effect. ''- � Size 8 Type HP,KW,KVr1,or KVAR � � �d � � License Nmnber_ ������ Lic.Closs �-�� U to 1 Ind- HNAL '� � f �C�in O� ���5 : Dver 1 to 10 Incl. _ �ATF �Y:��,;�tx,,.-�� VAtIDAT10N � .. Coniroctor �� Over 1C l0 50 Ind. �' FlNAL .. 4J� - � I om exempi Vnder Sec �ver 50 10 700 Inc. � �BY �,�,,, � ' � 8.&P.C.for this reason _ Ove�100 ' - `» ! E � � � �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 �- fxempiion for Req.Maint.Elect. �- � � � � SWGLE FAMILY �;emp.Power Pole&Appurtenances � i � � � 1 HOME OINNER-BUIIDER DECIARATION Sign with One Brarch Circuit � ' I hereby affirm th�t i am exempt from the Contrac�or's License .Additiana)Sign Branch Circuits - � � �' ��' j La�v for the f�llewiny reasan(Sectlon 70315, Business nnd � � � - Professions Code): � �%`° � g� ' ❑ �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,Bos�ness and Professions Code1. -- f� a m �,/;�j�, - �� CONSTRUCT!ON tENDING AGENCY �-�"'""-��— � �- I hereby affirm fhal ihere 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�l) 3� � �. (Sec.30D7,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 !� t obove informa+ion Is mrreci.�agree to comply wlth p!I Ccunty . ��� ordinances and State lows regulating Electriml wiring,and ._ . � he:ehy a�thor�re representatives of th:s County Io enler ppon 1 c� (� ihe obove-mentioned propert for inspec�ion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE /{GC-�I.E�L� /�-a�<-,d.,�r . �ignature of y�ir,�itiee G<�te � v � , , � a � �ss � z � � � C � � G r" 'S Z Z �" rn � C g � �4. �°fi � � � A m , � � rn Q� 1�.� f � � `I' Q �� ;� � z� „�y 'Y` 2 � � � O u+ � � q -s' p 1 � � ,(� ` �,. t. : c7 �� � p � m `� �� � a ': � �+. �s, �, ,,�» �,� � , `` � , 1 � ' � , , .t3 � � � � fl � ;�f'i� C � � lp � N � O � „` -� L 7 � � - � � - yy `�O^ fl -fSs�-o-�,�"�.y � N � .t �. 4 j �! 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