HomeMy WebLinkAbout1372A (7) � 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 -
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+ 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
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