HomeMy WebLinkAbout1650A � WORKERS'COMPENSATIONDECLARATION 76A663 t0/81 epPl l[^e�T1AN �At? �1 �PTRIP'A1 D�R�lA1T �_�.. §�'
I hereby pttirm fiat I have a cer}ificqte of consent to self "O1"" ravrra o m�av a ava� rm�m= -aro-am res a�o■
insure, or a certificate of Workers'Compensation�nsurance, � � >.
' or a certified copy ihereof l5ec.3600 Lab..C� COUNTY OF LO$ANGElES BUILDING AND SAFETY
? r. �`k � C�
� ic`�Z�!-A�a�i�! .�L� -
, Policy No Comoanva?�.�!����,�_� POR APPLICANT TO FlLL!N� JOB �
� � Certrfied mpy is here6y furn shed. , _._ , New Resideniial Bidgs,8 Pools EACH NO. PEE ADDRESS c.�."'� �.!�j f-�11yl-` K jU�J
g 7&2-Famil � — 5 �,. LOCALITY�����,��S-� L'�F''a�
� Certified copy�s tiled with aha county building inspec- Y,Sq.F�. , ��f� `�� �� �
NEAREST
� � tion deparlment. 'n` (} Multi-family Sq.FL CROSS S7.
iy1 /�! � � Resideniial Swimming Pools
� Date�1�,�—ApplicaM' ���,�.�L-1li�,� Y.d-/�Y1..�i . �2MNAME O �y
� CERTIFICATE OF EXEMPT�ON FROM WORKERS' Outlets:Rec_Light_Sw._ �r'�`A�� - �J
� COMPENSATION INSURANCE nooRE55. �"- � �;-'� �! �(
� This section need not be com leted it ihe work invoived b Firsi 20 '
� P y Totol No. qdditionol CITY � _`� � Tel.No. �
� the permit is for o�e hundred dollars(5700)or less.) v�nN cHecK
g -i certity rhat-in ine per7ormance oi the work for which this . AaPI.�CnNi
� permif�s issued,�shali not employ any person in any manner -
-so as to become subjetl to the Workers'Compensation Laws. Liqhting Fiztures First 20 � ADDRESS
Tota)No. Additional
� � G7Y Tel.No. -
Dote Applimnt � Fixed Appliances Not Over 7 HP PfRM!T ' �'�
� "��T�CE 70 APPLICANT� If, after making this Certificate of pppucANT �- ' ��
�nption, you should become subjed ic the Workers' Range_Heoter_.D.W._ f� � �--��'�
Compensation provisions of the Lnbor Code,you must for}h- Oven�—Dryer _W.M:_ ADDRESS ��-�"} r'�? C'
� -wi�h comply with such�provisions or ihis permit shall be �Top _FAU —W.H.— ��`y �"'^'""'"�`�'�
� -deemed revoked. CITY �"' iel.Na.�`��"r_' �
� IICENSED CQNTRACTORS DECLARATION .Hood _Fon ____Other_ . �
LICENSE 6R t�, �N
Disp. —Room Air Cond — �` ) Clas
I hefeby a(Finn thaf I am I�censed under provisions of Chapter9 KEG.NUbIBER�'-�'� - s��7� �� 'l.f-"� �
-�(commencing with Seci�on 70C�'J)of Divisiott 3 of ihc Bosiness � DI$?RICT f�C PRO`"�SSF,B'� � - '-
.and Professions Code,and my li[ense is in full force and effect Power Apparatus&Large Appliances „�''` ,� :
� �)p� ;^: Size&Type HP,KW,KVA,or KVAR- �� �J ���.. � � ?;
� license Nurnber 1���"��"T�r� Lic Class �'—��`-�- - Up to 1 Ind. FINAL �^, - � :
� � � ���— � Over 7 to 70 Ind. DATE : � �:� (t�`� VAIIDATION `�
Coniractor ��� -��-�_ Date ' Over)0 ro 50 Ind. �^ ��
❑ — -- FlNAL
_... „
I om exempt under Sec. pver 50 to 100 Ino BY y ! ,f, ��
8.&P.C.for ihis ieason Over 100 � .__ i G—'- " � t�i'9
Services,Swbd.,MCC&Panelboards I _� ��
__ _Da�e� 0-200 Amp.Under 600 V �
� . Signai�•e . 201-1(J(X)Amp.Ur,der 600 V -
Q Over 1000 Amp.or Over 600 V
� Exemption for Rey.Maint.Elect. .
. SINGLE FAMItY Temp.Fower Pole&Appurfenances
� - HOME OWNER-BUIIDER DECLARATION Sign with One Branch Circuit �
�eby affirm Ihof I am exempt from the Conirottor's License Additionol Sign Brqnch Circ�its � �" � �
.,.,a for the ivllowing reason(Section 7031.5, Business and . .
Professions Code�: - �- � .
❑ I,as owner of ihe property,wil)do ihe work and the Misc.Conduifs&Condudors 9
str�ctwe is not intended or otfered far sflle (Section Other(See Complete Fee Schedule)_ - ' �
_ 7044,Business and Professions Code}. ;� � a � � -
� CONSTRUCTION LENDING AGENCY _ � - �
'-1 hereby affirm thot there is a wnsnuciion landing agenty for - � t _
,the performance of the work for which fhis permit is issued PERMIT FEE �(Sub-Toio!} �! � �
�:(Sec.3097,Civ.G). - . �
, PLAN CHECKING FEE � . :
-Lender's Name � � � � � -
� PERMIT ISSUWG FEE ��-1`�^}� � . .
� �Lender'sAddress � - � - - �
�, l certify that i have read ihis applimtion ond state ihat the TOTAL FEE 'f��'��. . - -
� above information is correct.I agree to comply with all County � - � � �. �
�ordinances and State laws regulating Elecfrimi wiring, and
hereby authorize represenia�ives of}his County lo enfer upon _ - � -_- � �� �
rhe above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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