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HomeMy WebLinkAbout1372A � WC7RKFR5'(:OMPFNSATION DECIARATION 7M663 10/81 e pPI IP ATIAAI r.nD CI L�TDIr A I D��AAIT /3 � i hcreby.cnfvm t'nnt i nave o certiticnie ot e�onsenl to self "�""" `: : �ar��:d:� : 'vG� 6�av:a�i'vi�w G �i'si�ei e - II + ioso�v,o��c�nsfl�arE,of Wo�kers'Comuensation Ins�ran��e, GOUNTI°OF COS ANGELE$ BUILDiNG AND SAFETY �� i or a rertified ropy rhereo{(Sec 3800,La6.C.) � � �ry N�. (:�S�5�3`i��mpany TiVA FOR APPLICAPIT TO Fllt IN AO��E '1, i p Certified copy is hereby turnished. New Resideniiol Bidgs.&Paols FACH NQ FEE ' � 1314 �s — s � r ioca�rv �°• � Cerlified copy is filed wifn the cnumy building inspe< I&2-Farnily,Sq.Ft_---_ ' -� � t�ron depariment. Multi-family Sq.R. �— NEAREST � 3 Rasdentiul Swimmin Pools I ,CROSS ST. Uate �lo�Applicanf �'�,�`� M.,Co�Fte..r,-iC 9 � OWNEROR � �FI.PMNAME Anden Gtp. CERTIFICATE OF EXEMPTION FROM WORKERS' I MAIL � Oudets:Rec�Light_Sw._ COMPENSATION WSURANCE � I �ADDRE55 1Q74 Yark View P.Y. 3 (TFis aection need nof be completed if ihe work involved by First 20 i the permit is for one hundred dollare(SI00)or less.' 7mal No. Additional I CITY (;OV�.IIII Tel.No.96�-g5�+1 � "fl- I cert;{y that in the performance of the work for which thls � PLAN CHECK � APPLICl�NT permil is issued,I sholl not employ ony person rn any manner � so as to bemme,wbject to the Workers'Compensation Lpws. ��ighting Fixtures Frsf 20 ADDRESS TOI6�NQ. AddiliOnp� � �CITY 7e1.No. g� a, _Ap�licont yyFixed AppL�nces Not Over I HP PFRMIT � �.,.!ICE TO.4PAI�rAN?' If, ofier m�king fhis Cer!ificp:e of $ i I �qpp�ICANT �-T�� 2IICGL"L i:lectrie, ZAC. - Exemption, you shauld bemme subject to the Workers' 9 Range_Heafer_D.W. -__ � Compensahon provisions of the Labor Code,you musi Forih- Oven _�ryer �W.M.— � (ADDRE55 P.Q. }�OX 3.�..11 with mmply saith such provisions or this permit shall be To FAU W.H.._.__... � � - ? deemed revoked. � I I �CITY Tel.No. Huod _Fan _Other_ CFti»o 91708 �i1-6461 LCE�SED rON?RACT025�JECLARATION i �""" "�—�'`"--'--'. � Dis _Room Air Cond. — � '� � :ICENSE OR ; I hereby affirrn Ihot I arn licen;ed ur•,dar provisions of Chapter 9 �'� �� REG.NUMBFR (. ' Class ,N ? (ccmmzncing wdh Secfian?OOJ)o?Oivision 3 oi fhe 6usinzss Ui�7RICT NO. PkOCE�5E0 BY �' Power Appora�us 8 L�rge Appliances r and Professfons Code,ond mv qcense is in fuil force and effect. I I I �� � C� ; � Size 6 Type HP,KW,KVA,or KVAR � ° Gcensa Number_tt90��83 Lic.Class C-�.Q I i C.Y.. � Up to I Ind. � �` fINAL � � ! Over 1�0 10Ind. I,Y . DATF 1Z�!��p� Y IIDATIOM i.� Confrnctor I�ZECCYlCd.l Date $�2�/P� ' s� � � Over 10 to 50 Ind. � � �FINAL '=� . I am exemp�under SFr, Over 50�0 100 Inc �___.—i.�__—._..��._ BY t� � B BP,C.for thls reoson - Over 1W I _, x � ii i _ - Services,Swbd.,MCC&Panelboards � �,�+, --- Date: 0-200 Amp.Under 600 V �i , Siyna�turr ` 2p1-1060 Amp.Under 600 V � I '� � O � Over 1�0 Amp.or Over 6lb V r � � � r Exemp�ion for Reg.MninL Elect. i � ��j r, � I _ , ' SINGL'c FAIJ�ILY Temp.Power Pole&Aopurtenances t_ � � , k � �, �• � +� HOMF OWNEH-BUILDER OECLARATION �Sign wlth One Branch Circuit ` � i e, u� § I nereby affirm that I om esemp!from the Contractor's License Addilionol Sign Br�nch Grcuits � � j' e � w,(;,�� a Low for the following reason(Seciion 7031.5, Business and I � Professions Code): r _ � � Misc.Conduifs&Canduc�ors ! �� �� � � ��""" � I,os owner of�he property,will do ihe work and ihe strutlure is not intended or offered for sale Seclion Oiher(See Compleie Fee Schedule)— �n��,'a�J i , p 7044,Business ond Pro'essions Code). ( C��� � CONSTRUCTION IEN�ING AGENCY � i z�ereby o;i�rm�Ihol there Is a:on>tr�chon lending ugency for - ? fhe performance of the work for which th�s permit is issoed PERMI7 FEE (Sub-TotUl) 5Z.56 j (Sec.3097,Civ.C.). � . PLAN CHECKING fE[ � Lender's Name j PERMIT ISSUING FEF f Lender's Address pI ceriify thnt I have rend tViis applimfion and stote thnt�he TOTAL FEE 63.0 } above fnformatlon is rorred.I ogree to cnmply with oll County ( ordinances and State laws requlatinq Eledncal w rinq,ond I hereby outhonze representahves of ihis County to enter upon f the nbo e men�ioned roperty for inspection purposes. � a� (}�L4.� 8�2U/86 SEE REVERSE FOR EXPIANATORY LANGUAGE Signofurc ef Pennittee Date , ', . . ; • , , . ,. �. i ' .. .. . . � . . 'q . ,. —• , ' F� �� . '� , . . .' s , � • ' � {} , . . . . ` S . . . ' , ` . . . i a �, . . � . � ' " . � . 1 ' ' _ . � . • ',. . . � . t � . , ,� � : , �� � , , , � . ., � i. ' ' ' � �`� ,1 . .t . ¢ t � . 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