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HomeMy WebLinkAbout1211A (6) �'�/' WORKERS'COMPENSATILINDECLARATION 78A663 �aiat AppLICATION FOR ELECTRICAL PERMIT {� i �here6y atfirm that I have a certificate o1 consent to self insure, cE-eosG or a certifitate of Nrorkers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY u eopy therecf LSec.3800,Lab.CJ � ?9629� ST, �'UND COMP _ Po���yM��' ' Company ' FORAPPLICANTTOFlLLIN' . 'ro8 22372. KICKING HORSE EACH . NO. ._ . FEE� ADOPESS � ❑ t;ertified copy is hereby turnished. ,. . , . New Residential Bldgs.&F��sZ 4 � - � �d 2•Fami� S Ft 5 0 4 — � LOCALITY D IAMOND: B AR "�, Certified�copy Is tiled�with the county�buildirg inspection Y• n' _ ' ' �ypal}mpp1. ' � " . . . � . ' ' . ' Mulfl-10Tily Sq.FS. NEAREST WAGON.TRAIN LANE CRO55 ST. �Date�Z�29�89 Applieant �� BROWN"ELECTRIC Residential5wimmingPools � �- �� owNEqoR � � _ FIRMNAMEPIERMARINI HOMES INC ���� �CEFiTIFICATE OF EXEMPTION FROM WORKERS', •� Dutlets:Rec—LgM—Sw.— ��� 770 PINEFALLS AVE . . . . .. . .. . AODRESS - permiteis for one hund ed dolmara`5100)or�la BI,olved by the Total No. Aldditiooal-- - -- �- � CITY__ AL UT� , Tel.N. • M ' � PLAN CHECK �I certliy ihet in the performance oF the vnork for which this permit ��-�- �- ���� �� -�-� -- - AapLiCaM - �- � ' � is issued,1 shall not empby arry person in any mannei so.as to . __ become subject to the Workers'Compensation Laws.. L'ghting Fiatwes Frst 20� - - AD�RESS � - � � Additional '�`�" � � .-.� . ,. . - '�_� Total No. ... � CITY - -. . .- -..- Tel.No. �ate ApplicaN � � Fxed ADP��ances Not Over 1 HP NOTICE �TO APPLICANT: If,.after making.ihis Certifica[o ol PERh�iT Exemptlon, Range_Heater_ D.W. _ aPr�icANT BROWN ELECTRIC you shouid become su6ject to the Wo.rkers CompensaCan provisions of the Laboi Ca1v,you must Forthwith comply with such Oven_Dryer_W.M._ ADDRESS �13880 -SMOKE TREE ROAD � .provisions or this permit shall be tleemetl rewked. -.�. ,� _ _._..Top ._FAU.._W.H._._ . _ _ . . .- ��� CITY V zCTO RV ILLE -���-Tel.Nd�19- 2 4 S 9 0 5 LICENSED CONTR4CTORS DECLARATION� .., Hood— Fan. —Other_ .Lhereby aflirm ihat I am licensed urwer provisions of Chapter 9 Disp. _ Room Air Cond. _ - ucENSE oa _ _ . . Class. (commencing with Section 70001 0l Division 3 ot the Business and oSTRiCiAeER ' ' � Professions Code,and my license i5 in full force 2nd effeCt. ppvrer Apparatus&Large ApplianCes NO. PRpCESSED OV � _ ._ Size 8 Type HP,KYf,KVA,or KVAR � 0 CL��-.� � 230203 C 10 FiNA� • �license Number Lic.Class -�- -'-� --" � Up to"1 Inct." � �"��'"� �- " �- - � � �� - � � ��� - � BROWN ELECTRIC.. 7/29/89 we.1 to 101nc1. �ATE � g� VALIDAT70N 0 � Contractor - � �ate� � � "� � -� � � �- � � - �� Over 10 to 50 Incl. FINAL V ❑ � I am exempt under Sea � � __ .__ Over 50 to 100 Inc.. , BY _ � ._ . . . .._ _ . .- W .. ... ...... _ . ._._._._. _ d� Ove�100 ' � 88P.C.for this reason � .. Services�Swbd,MCC 6 Panel6oards. ... . . _ ._ _ � . � __. .. . ... �.............. ...._ Z . .. .... .. . --. . Date: . . . ._ 0-200 Amp.Urucr 600 V Signature - � 201--1000 Amp.Under 600 V- �� �� � ���� �- - �� ���-� ��--� �-- � - -- �� � � ��'- � . .. . ... . ....... . . .._..� .. -_ . . Over 1000 AmP.or Over 600 V � ❑ ExemPtion for Re9.Maint.Eled. � . . . . ............ .-.. . . - . - . . - . .. .. . --� - -- -�-- -�SINGLE FAMILY� � -- - Temp.Power Pole&Appurtenances .,.. .. . .. . . ... _ . . ._. . . . HOME OWNER-BIJILDER�ECLARAT�ON Sign with One Branch Circuit . I hereby aHirm that I am exempt from the Contractors License law q�itional Sign Branch Circuits lor the followirg reason(Section 7031.5,Ousiness and Prc!essions - �- �-- ��- � - - ��-- � � -" -- - ' ' ' codel: -�1 2.1,1 A - � Misa Canduds 8 ConduCtors � - - ��� � � � " � -�-� � ❑ I,as owner of the Property,witi do the work and the structure Other(Seo Comp�ete Fee Schedule)_ � #• • • • e 2 is not intended or ofiered for sale(Section 7044,Business � and Prolessions Code). ' -..... �.� _. - .. ... . . . . . - . . � . . . ..... ..� i • 191,50 � CONSTRUCTION LENDING AGENCY � � - - � � - - ��' � - � ��� " � � " � -� �- - I he26y atfirm that ihere is a construction lendirg agency for the • • � 9�'J�� � performance of the work for which this permi�is issuetl(Sec.3097, pERMR FEE --- � - � �� (�b-Totap -18 1 0 - �-�-� �- �- � �� , -� � - � a�.c.i. 0&29-8$ � ' .. PLAN CHECKING FEE-.... - . � �� ���� � � ��� � � � �--� � _. Lender's Nama PERMfT ISSUING FEE.,.. _ _. _ .. .. .ZO- S -- --. . . . . . Lender's Address • I certify that I have read this applieation and stale that the above TOTAL FEE _ � _ _ . � $-�.lcj j..5 -_ _. . . inlormatbn is earect.I agree to compy with all County ortlinances and State laws regulatirg Electrieal wiring,and hereby authorize , , _ . __ . � _ . . ... . . . _... . .. .. . . .. ... . . . . .. . • _ _ . . representatives of.this County to enter upon tho above-mentioned pmperty for inspection purposes. _. � . SEE REVERSE FOR EXPLANATOFY LANGUAGE. ...... _ . . DON E. BROW� AUGUST E��r'�89 Signature ot Permittee Date � . �' ..,. ....`v -_ ... . . ,_ i_- - . r.-; -.. I•- --{� --I- i--I--�I,_I._.._I.. _ - 1---_i i ..j i � i i , i 1, � I � i . 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