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
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