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HomeMy WebLinkAbout1653A (9) 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 - � � m -� r.o o.c�'v y, � c g.- m N a•am o �mQ��0"6 °-��s ' t.cm�s�aQ� oro o m°'vt�'��a '""�:= � °"`o rno`. dv' ss 3@'=a ° ET � o '" . . .`0 M,�'0_a''.p C v�'}O.Q v` ,�,�-,. os,- '�"r G 7i > `N O �-O . - Q t T'�y� G � � p � C� p O�„�fl p'� � � - d - � . . ,x r.o m c,„ m N 6 o m C .p,,. 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