Loading...
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 ��`� j� � ` ��-/' - �, �� � ig, tu�e of Permittee ^cts 1 � � 1 � . . � - � � � ';' � � u� ' � y =' �+ ° � " c� �3'b a� �,i a � � � c �. � �, -� ; � ��` � � � Q ��m'o � � Q � d� Q�-� �� � y , � � c � � �� �� 1 �� o�� � , � � . ����� '� � � � i ': v � � p!1 � o -� 1 � �.� �, k Q • ' 1�.� ' . '� . � �`". ` �L � � � . ' � ` J� +' a � 1 � } ,� � 3 ' �`, . . . . . . . . . t r " 9 ,` F' v,c�3�°.°���m 1 ,� q�,S 4 � 4AD� U f'� "r N'4� C9 @ CS � u � O�,v � � °o ^ ' IJ� � �-9 0 'J� � '°� � � Q '-^ ;�J � f2 '3 � 7'` 6�;�L ^4 fl N �v�"�^�!'U 3 /4 't4 � � O n � � = "� � s�tD ��'��� � oo�;�`�'� 30o rn ' � C'� x °_�•m � ��'`° ��'o��, ��a�"� � c = � �° � @ � O..� -..O r' an e' '�L • � GS �. rt 6 � O � Q -a.,� 'a £ � � � gp'�tD �� 49 ,�q o C � �Ll o r,- fr-^' � �.� W o3 �-W n �� rn � e�� as � � D� O . 7- G =o c..�n° w n � '�'" ^4 �.ro '" � $'c n� = o � i� F� . N ro � ��9�� 3 fl"7" m p d �J � �"� �^.���� �'�^�� � Q ' � p iD � N an O �U'O � � �� t�,�Q � W Q <J. f" p � .�. s����-� �^a ° °.-�a 'Y� �-� �'� '� %c � o �, � � n —m s n �y-¢a �i •n �, -, . ,e w ;tf m r�-ca � � o � 3 '�.c �@ ° "� w' �ep ° 7> v c � ''° O'� � -� o � r� `p '�3-° .� ' � "a ' C �� y 9� U 3 % � W ..i. 4 t�� gp �='u�� ilr� l�. C9 K O Q �^ �M11 � u' � =6 �O°� A G p � A i). Z . .. p 9 Q !D'6 7 � q 61� _��p O U � Q Q � G r3 .^-. � . - ()TS �� < Q�•'. �a � -m e�i..,.7 � '6 Ct {lII � 0.7 7 3 . . N Sr ^ � a� 53_S < °A p 9-Q n � ft1 &4-�`� �9 G t3 �-� �, � 3 'S � A °m—s 3 m +� ° o ro � f s�o cn m �� ��' ° —�'�" o �,.r' . ' �'�tfa �y �� p Jy � Q �4��3"� � � "4� N .✓"` p a �L1 �4 3 Q LS'� p N '9 .'-O �r,�"' . 3'.� 3 Sp � � ' �- � . ' , � - (p ' �p = � .� C. ' �f j � a =o p a;< �,�,,,.,,_....^.""°' � _�....��--�-���`�"� �� �--