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HomeMy WebLinkAbout1149A (5) � - WORKfRS'COMPENSATION DECLARATION 76A663 i0:et �ppL��qTl4N FOR ELE�TRICAL PERMIT i1 . I hereby�affirm ihat I hove a certificate of conseN to selt CE-806G § ms�re,or.a certificare oi Workers'Compensaiion Insurance, Ct'U�ITV OF LOS ANGEIES .r/ �,z� �URDiNG AND SAFETY ��� �S� � 1 cr�o.certified mpy fhereof(Sec.3800,Lab.L.�) o�-y ! ( Poliry No. Company FOR APPUCART TO FILI IN � B �y �/ f �, � n i [AiH NU. ctE _;��DP.cSS "h 5`�,;�� �o L� � C% � i � � Cer;ified copy is hereby furnished. New Residential Bldgs.&Pools � � Certified copy is filed with�the county bvilding inspeo 1 &2-Family,Sq.Ft— 7�—��L� _ $ LOC,ALITY � ,,., i,ion deparimeni. , . Multi-family Sq.R. �va � -NEAREST i � - � CROSS ST. . I "7 _9 C3,qPP�can Residential Swimmin Pools pbyNeR OR � � � d Date_�A � �=G��,�,g� � wy� � �FIRM NAME / �� CERTIFICATE OF EXEPA,P?�ON PROM WORKERS' � � ! ' '�"-' � ��MAIC yj� - Outlets:Rec_tight`Sw.__ 1 � • � COMPENSAi�pN INSURANCE � ��/ Firs120 - '� g� p��RF55 �- . �, � (This section need noP be mmpleted if tbe work invalvad by Tot�l No.�_ qddiiional i CITY �(} ��y�u Tel.No. j, _ � � y 4he permi4 is fo�one hundred dollurs(5104)or less.) ' . � I certif thot in the erformonce of the work for which this PL4N CHFCK C3j � � y P � I APPLICFNT `� / � permit is issued,i shall not employ ony person in ony manner � � so-as to became subject to ihe Workers'ComQensation Laws. Lighting Fixtures First 20 AGDRESS__ - - - � Total Na Additionaf -.—. CITY Tel.No. Date Applicant - �- ���- fixed Applianws Not Over 1 HP pERMIT `� - - NOfICE TO AFPLICANT: if,-after making this Certificate of qpPu�qNT /4..Q j� ,. � "'' u� �' � �_ Exemot�on, you sheuld become su6jec« !c the Workars' Range�Heater_D.N,i. — � � - -� Compensahon provisions of the labcr Code,you must forih- Oven _Dryer ,—VJ.M— �.4DDRESS ''7 �' Ai.ta�S v .�- � with ,omply wirh such provisier s or this permit sholl be lop —FAU —W.H.— - � deemed revoked. �CITY �� �� ����S Tel.No.� 7 � �� � . Hood —Fan _Other_ ,� LICENSED CONTRACTORS DEC'IARATION i LICENSc OR I hereb�affirm thnt I am I'censed� ide p ovisior�s of Chapter 9 Q�sP' —R°om Air Co d. — �REG.NUMBER J��•� �c`� Class. � '� � (commenc�ng wlth Sect�o 7ppOJ of D�v sion 3 of the Business � �7STRICT NO_ � PROCESSED BY � � nnd Profess.ons Cod aad .:�!i �e is�n full foree ard effed. Power Annorntus&La ac Anpliances � � � Size 8 Type HP,KW,KYA,or KVAR (� titense Number.-�Lic.i;lass_.�� . Up to 7 Ind � �FINAL °oJ� � I r �✓Y� s Over 7 to 10 Ind. DATE j ;p,.-��, g_.,.� VAIIDATION � Conirac!or���ZP7 ���+��-S" �ate '�'y���•�+ Over 10 fo 50 Incl. � �- r- FINAL q� ❑ I am ezemp`under Secl..... Over 50 to 100 Inc. BY �„�..--��, ._����,,,..- � �, � B.&P.C.for rhis reason — Q°ef�� �� �- I � Se ices,Swbd MCC&Panelboards � �°� ; S Uate: 0-200 Pmp.Under 500 V — � � Signature 207 -1000 A ip.Under 600 V �, ' � ❑ Over IOQd Amp.or Over 50p V � Exempiion for Rsg.Maint E;ect. � � SINGIE fAMILY emp ower Pole�Fappur�enonces HOME OWNER-BUIIDER DECIARATION �Siyn wi�h One Branth Circuit � �i I !`.!N I hereby affirm'ha�I am exempt from ihe Conirr�c?or's License -qdditional S'gn$ronch Grcuits .y: Law for the following reason(Secti�n 703L5, Business and . ;q a � r�. e =<'� Professions Code�: � ❑ �,as ov,�ner cf th2 prop�r�y,will do the w�ork�nd the �Misc Conduifs&Goridociors ( � �.c;�,: _ strvcture is not in!enden or offered for sale (Section Other{See Compiete Fea Schedole)._ � � �-z v .� -�` 7044,Business and Professions Code). -_... CONSTRUCTtON LfNDING AGENCY . � G�V.:i"�7- I hereby a`firm thai ihere is a construction lending agency for � . the perfurmence of ihe work for which this permH is issued � pERMii PLE (Sub-Total) ,��3 5� . . � (Sec.3097,Civ.C.�. PLAN CHECKING PEE Lender's Name PERMIT ISSUING FEE fd ��� . �� Lender's Address . � I certi'ty that I hove read this applimtion and sfafe ihat the TOTAL FEE �,7 � � .,_ ahove informafion is corrett.I agree to comply with all County �- ordinances and Sta�e lows reguloting Elecfriml wiring, cnd � hereby�uthorire representatives of this County io enter upon � th ove-men��oned prop rt for inspedion purposes. � ' 9 SEE REVERSE FOR EXPLANATORY LANGUAGE ��� ,.� �. �a�Ps- � Signc!ure c�;rt�ittee D�Pe - 1 1 � � � � S � m ' `n f '�J � �i v ":' ..�.i G � � C ��,,, v Z � '� �' m � � � m �' � � � �° 4�y. 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