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HomeMy WebLinkAbout1733A (10) , �NORKERS'COMPFNSATION DECLARATION 76AN:3 i0/el A DDI IP ATIARI C^� CI Cr"TD1�'A 1 DCDAAIT .^^ � I herr.by�ftirm that I hnve a cert�tica�e ol consP��t to self �-�-ov�,�; i�i i Liv��'e i�piv i v�� ��e.as�BSi'viiir E iri�GVi'e i , .. .,...,. _ _ ._ ' ',osure,or a rert�ficn�e ol W��r4ers'Compe�soiroo I��si�-a���e. COUNTY OF LOS ANGECES SUILDING AND SAFETY � o�^;.=r`�fied copy�hereot(Sec 380U,Lob C.1 � ?r�li:y No. Company _ FOR APPLiCANT TO PILI IN J03 ' �...�,� � ' ! f"'1 - aookEss �/�'. �'�'....c��,-i=�,���t!-�Z, .�d'<. , L,� Certified copy Is hereby fumished. Nr•.N Residentiol Rldgs.8 Pools � EACH NO. fEE _ . , iOCALITY I.+ ""�% !�' • ' r � � .S 5 ✓Ckt��f G(-'�� : :. �.� ,:>��_^) Cenified copy is filed with rhe county building inspec- 1 8 2Family,Sq.R. � � � tion deqortment. Multi fUmily Sq.Ft._____ � � Ih !�NEARESi ResidenhalSwimmingPools � I ' CROSSST �1 ; „s _ Uate Appiicant �— i � � I OWNEROR1 �G"�„i1ri,�,-_�J'�!;1✓=,;v?i:'-��-�J/ fIRM NAMP . CERTIFIG4TE OF FXFMPTION FROM WORKERS' � I � q!l i '� Outletr.Rec�_Light�5w.� .� I�. � , .s�`�' .'f COMPENSATION INSURANCE I < �y � ,� g a.�ORE55 ,-"� L'"�y'��''-'- Flrst20 I �—� L�. -✓� 7 �,ty2_y. , � (This sec4ion need nof be camplefed if The work involved 6y � I � CITY _ �����=�,� ___ ...Tel.Nd��"' f �Go•� � fhe permif is for one hundred dollars(S1tl0)or less.) To�ol No. pdditional r ^ ` /" ' i �°IAN CHECK` � I certify thot in ihe performonce of fhe work for which this � � �APPLiCANT permil is issued,i shn�l nor cmploy any person in any mannei so as to become suo�ed to ihe Workers'Cnmpensation Laws. ���9hl�ng Fixtures First 20 ' AD�RESS Additional � � -- Tmd�No, I I ICIIY �' / Tel.No. Da}e Nppllcant i � � Fixed Appliances Not Over 1 HP � � PERnnii • `. ^JOTICE ?O Aon�JCP.NT: I:`, after n�aki��� ;�s CcrHfim!c c' � i •�_=�-.- `' Exemption, you should bewme subje�.t'tto the V✓orkers' Ronge_Heater_D.W._ �AaPLICANT ,`.'p,,...-E- �. -(.{:.-' Comnensation provisions of the Labor Code,you must forth- Oven _Dryer —W.M.— ADDRESS � - :�'.f .f;�� � � ith compl wi�h scr.h rovisions or this permit sholl be 7 ; �h�'�'! �1�"''3 'f��"� e'� ., Y P op _FP.0 —W.N.— ` deemed revoked. I �CITY Tp.No. :. Hood ._Fon ___Other_ ° LICtN�ED_ON?RACTORS DE�LARATION � I ��,�;:eNse oR � Disp. —Room Air Cond — �I � ass. $ I hereby offirm that!arn lice.nsrd under provisions of Chapter 9 � ��+- REG.NUMBER � .,,,, ., (ccmn:?nany witi:Seclron 70JOj of Dlvialon 3 oi Ihe ausiness i I � �uiSTRICT NO. P CES�D dY C._ �. Power Appprp!�s&Lurqe Appliances ` ond Professions Code,and my.cense is in tull force and effect. i ' t:) $ Sire&Type HP,KW,KVA,or KVAR � i i �� --F-'...-�����.;.,x„m...� � " License Num6er_ lic Class___ U to 1 Incl. � : i � iNAI r"'•• � O�er 1 tu 101nc1. � i I ! �DATE �% .<"�;,;t�„t �� � Comroctor pote �--i VALIDATIDN F;' Over 10 to 50 Ind. ' ' FiNAL ii: ; ❑ I:�m exempl undcr Sec__ � _ Over 5�to 100�nc. L—^—[.__.T_—_ BY / . . ;� I I � � 8.8RC.for ihis rcasnn_ . Over 100 I����► . ` . _� � Servires,Swhd.,MCC R Panelboardz I I I i � � — _ �ata:_ 0-200 Amp.Under 600 V �}— `. ' ��',`�1 S�,c�n�Nre _ � "<01-1000 Amp.Under 600 V � - r� e e a �j .. � �y—}— � ff � ❑ Over I WO Amp.or Over G00 V j i 1 1 Exempfion for Reg.�'vlaint.EIec1. � I I I � � z 1 :A �� SIiJGiE FA]vtILY Temp.Power Pole&Appurtenances � � �x < HOME OWNER-BUILDER�ECLAP.ATION " ° ' � •'7-%-- Sign with One Branch Grniit j I hereby affirm!�nat I nm exempt irom ihe Conir�ctor's Lfcense . i Q f.(i �-"� ! Law for Ihe fo!Icviing reason ISeclion 7031.5, Business and Addinonai Sign 8rr�nch Grcuits � ? Profe ions Code,'.: � I I j Misc Conduits 8 Conductors i I,os owner of the property,will do the work ond�he i 3 strur.�ure is not inlended or offered for sale (Section Other(See Complete Fee Schedule)_I '', � � 7044,B�siness and Professinns Code). � � � CONSTRUCTION I.ENDfiJG AGE�ICY a , I hereby a"irrn Yhol tl�ere is�conslruc�ion iending ayency for ` � y the performance of the work for wh�ch this permrt is issued �PERMIT FEE (S�b-TotolJ � �GA, � (Sec.3097,Civ.C.). �, PLAN CHECKING FEE . � Lender's Nome___ .T� � PERMIT ISSUING FEE �; tender's Address V I rertify tho' hove�ead+hls applkotl�n�nd s�a+e tha+rFe TOTAL FEF !�.'� � nbove inl m tion�s c�orrecl,I oqre.e fo comply wilh oll Counly ordina e.s nd State Inw regula4ny Electncal winng, and j her y Qu orize represf tahv of fhis County to enier upon � �h abo - entioned per for inspeciioo p r oses. � � / SEE REVERSE FOR EXPLANAiORY LANGUAGE ��v a � --------- ------------ $ na re o Parminee Date 6 . � � ' � . � � �. , . ,. . 3 , 1 E . . . � . .. , � � .1 . , ` . 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