HomeMy WebLinkAbout1055A (5) WORKERS'COMPENSA7�ON DECLARATION 76n663 10/61 ��PLi�ATI Sy F�R �CCTRI AL IT �
� ,ereby aff�..., N.�r i ti�„o��e..ificote nf co�si.�••=,sel< CE806G 9 �-----__�_ PERIIl�►___ �
�ue,or a certificate of Workers'Compensation Insurance, CQUNTY OF LOS ANGELES BUILDING AND SAFETY
a certified c py rhereof(Sec 38D0 ab.C.)
�licy �5����O���ompany ��'���c�Y . . FORAPPLICANTTOFILLIN J08 e"'S,� �
� Certified co c hereb fumished. ADDRESS � �C'„y: �', S� N �%�� �-
PY'� Y New Residential Bldgs.&Pools EACH NO. PEE _ � �
1 &2-Famil � — 8 LOCALRY �_ ��J �}��A
#� �"�Ceriified capy is filed with ihe counfy building inspec�/� y,Sq.Ft _ - �
fion departmeni. ! f !1 Mu���-fnmily Sq.FL �NEAREST / F 7� s
,,.. ) �/ CROSS ST�/j Y - �C..t'�i �';
� „�f� L J� Residential Swimmino Poals ,
afe � �S Applimn � �� j� ��t +Lr, OWNEROR� { f
FiRM NAME.- �� ! ��>
CERTIFiCATE OF EXEMPTION FROM WORKERS' OuNets:Rec_LightlSw._ "N'A�� �. % a �' ''� /�
COMPENSATION INSURANCE ADDRE55���+t,`.�� �%,., qJS2k9 $GE -v .
This section need not be eomplefed if The work involved by Total No. Addi?onol CITY �p" �r?p��,�,'1 Tel.No.`���(�s i:3,aY3 J
fie perml�is for one hundred dollars�(3100)or less.) . pwN cNecK �
certify ihat in the performonce of ihe wnrk for which this APPLICANT .
-� permil is issued,I shall not employ ony person in any manner �
� so as to bemme su0jecf to the Workers'Compensafion Laws. Lighting Fixtures First 20 ADpRESS �
Total No. r+dd�tional �
C(TY Tel o. f\
�� 6a9e Applicant � fixed Appliances Nor Over i HP PERMIT /
�:,�. NOTICE?O APPLICANT: If, a(fer making this Certifimte of � �APPUCfiNT,=`r- '�o f"� �i ���n t �e� .
Ezemption, yo� shoold bemme subiect to the W'orkers' Range_Heater^D W. _ -
Compensat on provisons of ihe La6or Code,you most forih- Oven .—Dryer —W.M._ ADQRESS 1 ,�' i� .
� L� � :
�` wiih comply with such provisions or this permit shall be Top _FAU —W H.— CITY, t Tel.��¢y - �
� deemed revoked. Hood ._Fan _OtFier— '-.�'�����'��� -`" '.5��'���'� ..
IiCENSED CONTRACTORS DECIARATION �!ICE SE Oe ^r'�
1 hereby affirm thnt I am licensed under provisions�of Chopter 9 Disp. �Room Air Cond. -- �R�EG.NUMBER-������> � Class.�r��
�(commencing wiih Seciion 7000)of D vision 3 of the 8usiness I IJ1 ISTRICT NO PROCESSED BY �
nnd Pr�fessionsCode,and my license is in full force and effed. °ow.er Apparalus&Large Appliances � /Q a
��. �'i /�' Siee&Tyoe HP,KW,KVA,or KVAR� � �
Ccense Nw�6eF������ � Lic.Class� Up to 1 Ind. fINAL - "�-
�]� (t j i
�{�'(J'f 9�P R�! — — Over 1 to 101nd. ' DATE y/� ��7'� VAIIDATION �
� Conir f •� �
❑ 1� � r� Dafe Over 10 to 50 Incl. � FINAL �, ���
I am exempt under Sec. Over 50 to l OD Inc. BY
B.&P.C.for ihis reason Over 100 � � � �+������ �
��._; _pa�p. _ Servires,Swbd.,MCC&Panelboards � � -
0 200 Amp.Under bbb V
�";. Signa�ure-_— --_— 201 1000.4mp.Under 600 V ��-�- .
� Over 1000 Ainp.or Over 600 V � � � ,
Ezemplion for Reg.Mn�nL Elect. I
s
S�NGLE FAMILY � �'� � - �
-�Temp.Power Pole$Appurlenantas � / 'r� � � c,�.�;(�
ix�.., HOME OWNER-BUILDER DECLARATION -Sign with One Branch C�r<u�t . . _
� I hereoy offirm thaf i pm exempl From the Cororactor's License �, � g w -
��' Low for the following reason (Section 7091.5,8usinass and -Additional Sign Branch C�rcoits 7i �'�G� -
C'i Professions Code): �
�L' ❑ I,as owner of the property,will do the work and the -Misc Conduits&Conductors -.� a e�j`���' - . .
t '. strudure is not iniended or offered for saie (Ser.tion �Other(Sez Complete Fee Schedule)_ � � e. a ('p .{)?}
�7p^e'� 7044,Business and Pro(essions Code). � - �
'"��� CONSiRUCTIONIENDiNGAGENCY `��=� , `�� \.SY f`J `'�%� � � �~'
�, - I hereby affirm ihat ihere is a mnsiruction lending agency for - � _
f�ri ' ihe performance of the work for which this permit is issoed � PERMIT FEE � (Sub-Total) , - .
��::�. (Sec 3097,Civ.C.). .
���._� � PLAN CHECKING FEE � -
Lender's Name .� �
�,� - PERMIT ISSUING PEE - . ��J
� Lender's Address �
I certify ihat I have rend this applimtion and state ihat ihe TOTAL FEE �� �S� �
� a6ove information is corracl.I oyree lo comply with all Counfy , � � -
, ordinpnCeS and State la s regulating EleUrical wiriny, and � . �
- hereby aut!7oriz fepre ntatives of this County to enier upnn �
�''�t ove men - ed ro � spedion purposes. .
r t SE6 REVERSE FOR EXPLANATORY I.ANGUAGE
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