HomeMy WebLinkAbout1653A WORKERS'COMPENSATION OKIARATION � �6ne63 �o�sF qpp��CATtON FOR Ei.ECTRI�AI PE�tMIT �j
I hereby affirm that t ha ve a certifimte of conseN to self �'&� �
insore,or a certificate of Werkers Compensatian tnsucance, COLNTY OF LOS ANGELES- B'.UILDING AND SAFETY
ot a certified copy lfiereoF-(Sec.3806,Lab C)�� �� - - � - � ��
Polity No. '�.�Q(�Qdmpony �:------jj�,--- FOR APPliCANT TO til{IM�- - JOB - � . .
erfified copy is hera6y fumished:- - - EqCtt Mp_ �E ADDRE55
, .-. . Naw Residential Bfdgs.8 Pool
Certified copy is filed�wiffi the wunry bu�idiug inspec- 1&2-kamily,Sq.Ft� f � — s ��'°'��4K
-��tipn department ......� ... -.. .. - ..Muki fomily 5q.Ft. � - — �NE4RE5T .
�Datc7-�7-RS�- qp.p �'f'« �. Residertiial Swimm'rng Poois CRO55 5T.
. (icanf . ��-� F�p1'�{-Yi C OWNER OR. .
FIRM NAME
- CERTlFECATE OF EJCEMPiION FROM WORKERS' Outlets:Rec_Lighl�5w.� � �
: CpMPENSATIOM INSURANCE � A�pDRE55
First 20
(This sxtfon nQvd not 6e`tompl�ted if ihe worEc invofxad 6y. -1oto1�Q Additianal C�TY ' Fel.N 1
� <F�a perm(f Fs for ono 11Vndsod dsNars(5108)ar ieaa.} -. . . . � PL4N CNECK � ._ -
1 cGrtifp ifiai"rrt ihe perSormartce�the-work fnrgrkuch this.� . � a���T _
� permit is iss�ed,I shal(nos emp{oy any person in ony monner -
so-as ta 6emme lubject tc.tfie Wotkers`�-Cotnpe�satiarttawa Ligihiing fixlures Firsf 2(? ADIIRE$$
Additional . .
� . . . . -__- .. �otol No. CITY Tel.No.
F Dnte�- � e�^licant �� Fix:ed A 6ancea Not Over 7 HP
� NOTICE TO APFLICANT: If,ufter awking th�s Certificate�of � pp � PERMIT '� �F
" Ezemption,"yo� sFould bemme subiect to ihe Warkers' Range_Heater_6.W. _ APVLtCAM _�"_
Compensoskon provisto�ra#-thakabor`Gecis,-�y�€-�c�#mtk.. . .G3ven-_-Dryer-_W_M_— ADDRESS
�- with��comply.with such-{aro�isions-oe th�s-permit sha{I be Aop _FAU _W.H._ ' �'�" ��� �
: deemer}reroked.- ' - Hood _fan _Other_ e1N Tei.No.
UCENSED CONTRAEFORS DEClAR.4TION � ���aR
. t herehy aHi[m that 1 am liaemed under provisions of Chapter 9 � 6isg. _RoQm Air Cond. � REG.NUMBER � C
(commenc'ng witfr-Seciion SOQ6}of Uwrsion 3 of ihe-Busxness Po�rrer_Apparatus&.large Applionces DtSTR PROCESSED BY
a�dRofesstansCode.andrny,licenseisin}ulffineaund�tieci. .- ... ..._ __ �_- --_ --. __.__tETNO... ��_. �
- .--.�. :___ :_ -:- - _. �ze.B�Fy�ftP JS'K,.KYB._a[xVAR `- -_ - .
Cicense Num6er- Q�,Z��Q�$-- ..1�c-C#ass C-til �" -- ---- --. _.. . -.. Q
--- --- __ _.
. . . �-Up�to##act:_.. . . PINAL . . __ ....:_-:. _...�- . V
- Eantrnctor FTprfcr'itra7.- .tMta :7-�.:Sr3 .._ ... .Over t fo IO IncL DATE i . -��-' K �
. t- ���.�L_,. YAlIDATIpN 0 i
- -�23ver 10 to 50 1ncE . FINA � �y 'i
. ❑ .{amexampfundee�Sea -------- ---._.. ------ ---�ve�SfT-to�70Q�Mc� ----- --- -___ ___ BY�- -- -__ .... - -- . . _. �
� B.BP.C.far this�reason--� --. _ _ � _4eeec.7.90..,.. . . _.. _ _._ . ____. y
- � � � �� Services,Swbd.,MCC&Panelboards � - � - Z
Date� �
� - _ __ ._.. ..__-__ -.____ .__-. -_ . __-__ _-4-200ATa Unde[.6f1QY________ -_— .__-.__
..___. ___.._ __._.. __
�.�Sigrmivre - . .�Ol-.t(l00 Amp..Under 60Q V
� . . . . - __.._ __...---- ._---- ._. ..-t]ver t00Q AFnp.-w Over-606 V--- � �}6��J�
-�Exemptian for Req.Mtnint Etect � �
.. . . ���a�� ��
. __SlNGLEfAbtICY-- _---_ _ . ._... Fernp.Vawer Pole&Appurtenonces - -
� �- - HOME OWNER-Bt1tLDER-DECLA2RTION- � Sigi n with One Branch Circuit � •��Q 5,�j Q
1 here6y offirm ih¢t 1 nm.ex:empt from the Cantractor'slicanse- �Qd���w�a�Sigri.8ronch GircuiK�--�-�--
._ -._____._. - ....
law fw tha fallow�ttg iec�Soro(Se[tioi;.7IX3t.5.�6usiness crsd.: . . . - . . ... . . . .. .- . '��� � Q J.�{}c
� Profeuions Code):- - � � �
- � I,as owner o4 the p roperty,will do the work and fhe Misc.Conduits&Corrductors � -
OZ25-85
� strucfure is not intended or offered for soie(SeUion OtF�er(See Complete Fee Schedule)_ � �
70<4,Business and Professiona Code). � �
� COMSTRUCTION CENDING AGENCY _ � � - . �_ � �
1 hereby affirm that there-is o-construciion-lending agertty!or� - - --
the performance of the work for which this permi�is issued PEfZM1T FEE (Sub-Total)
(Sec.3097,Civ.C.). � . .
- - . � � � � PIA�N CHECKING FEE
tender's Name - � . � �
� - - PE2MIT ISSUING fEE . �
tender's Address � � � �
- I certify ihat 1 have read this appiimtion ond state thaf fhe TOTAL FEE - _
above inforrtwtion is carrectt.I agree io comply wifh all County - _ � � . .
ordinances ond Stafe laws regulating Electricol wiring, a�d
. here6y authorize represeni-atives of this County ro e�ter upon � � - � .
� the 6ove-mention d property for inspedion purpose5. - �
�y����� SEE REYERSE PQR EXPLANAFO-RY LANGUAGE- - - -
� Signature of Permittea - ate - � �
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