HomeMy WebLinkAbout1643A W�RKERS'COMPENSATION DECtARATION - - 76.4663 t6/et APPEtCATfON FOR EEECTRICAL FERMlT �
� I here6y affirm ihot I Fwve a certificate of consent to seif CE-806['
. insure;or a certificote of Workeis`Eompensation Insurance, [Q(JNjY OF�QS ANGELES BuI�IN(�s AN�$AFET�/
or a cwtified.copy thereof(Sec.3800,Lab.C.) � - . . .
� PQolicy No.j�ompany. .. �n -.. . . . : . .FOR APPt1GNT TO FILL IN - 10B- _ -
�ert�5ed copy is hereby furnishad. __,_ __. New Regidential$ldgs.� �CN NO. Fff ADDRESS
_ _
�Certified topy is filed witk the county building inspec- 1&2-Family,Sq.F f — s ��'A��TY '
NEAREST
• fion deportment Multi-fomily Sq.R . �qp�St.
� pote 7-22—g5. .. Appliconf �"ttO Mr`��� F.�t-�t'_i':riC Residential Swimming Pools .pWMER OR � - .
.. . _ _—_ — .. FiRMNAME AIY�PSi
IY
� . CERTINCATE OF EXEMPTlON FROM WORKERS' Outlefs-Rec_Light_Sw._ � '�'�t- � - - ��
� COMPENSAiION IHISURAPICf- � - � AooaESS �-
Fint 20
� . (This�ectiart n�d�wY bo wmplated tf the work-Inrolwd by Tata[Na. Additionaf - Gtt � Tel.No. ' �
iko EwrmSt ia�for orw handred dokiars(Sf60)or 4o�s.) . — — 4]. -
�. f certity that in the performance of the work tor which rhis � PV+N CttEC�c _
. permit is essoed,I sFiaff not emp�oy any person in any manner - a��� -
, so as to become subjecfi fo'tHe WolkePs`Compensation laws. Ligbtiog Fixfures Firsr 20 ADDRESS
_ .. ._._ _ .__: . . . _ Addi�ional ' �
Totoi No. - � �� CtTY Tal.No.
Date - r�icani Fixed Appiiances Not Over I HP
NOTICf 10 APPtIG4NT: lf,-�after makin tfirs Ce�tifimte af �RM�
Exemptron._.You�5tioutsf:6ersame.subje9c-k to ihe_-Wor4ers' �:._ .=-Rsv�ge�HG�ter_D.4Y..� - .. APMICANT u n .
- Compensation prnvssions.of i!u{nbor...Eade,-You mers##wih- � Oven _Drye� _W.M._ - A�R€55 ��1
. with campfy with �h prou�sio�a azt�this perm�.s}wkl be., Tpp. ._�€AU_..—W�.H:--� � � � .
.. deemesF reuoked. . �...,. . _ .: _ . -. .. . .. . , ... ._.... . CtTY � � � iek.No. _
� -- LICENSEfY-eONTRRC70RSt�EtARATf�ht-� - Hood _Fan _Other_
� Iherebyaf€irmtkwtkam�'teensedutEdetprorisianse€Ciiapfer9 .. 6rsp: -_-Raom�iknCand.._._ . . - REGNNUh56ER �2�748 Closs.
i rt C-10
:` (comre>encira�-�.vi�Snca'rcuc--7E�BB}'af{Iivisiorf 3 o#�Hrc-Business .- . ..-.. � . 645TRICT NO. PRfKE55ED BY
' andPro€essi�na.G�e;..��mar.i��ersseisin4ufl�vcca�d�fect.. . .PowefApparatusBLargeApptiances . �.
- � � � � Size&Type HP,KW.KVA,or KVAR� � � �� - a
�- l4cense Numbw ���Q748� -t;c Clnss C—Zf} - !� - . . V
�Up to i fncl. D� tr I F S �
Fl�r-�t-riral 7-22-$5 ave��fo}o i�d. �}� va�warwN
� Eontrotlor ' -Dare _ Over-}pqEtS@�rx6� - FlNAL - . ..... ... . .. .. O
- �❑�.�1 am ezempt cmder�5ec. - �- � � .....� Over 50 to t00 Inc. .BY � uVi
- . �8.&P.C.for ihis reason Over 106 � d
�
- - � � - � Services,Swbd.,MCG&Panelboards � - z
, - 6ate: � 0-2W Rmp.lJnder 6q0 V
. . S gnaiure__ .... . - .... 241-:1000 Amp:Under 50Q.U--. � ... '�.�6�'��
� Over 1000 AmD.or Over 600 V #��� � �"�
a Eaemption for Reg,Moint.EFect. - . - .
� SINGL€FAMILY Temp.Power Pole&Appurtenonces - '����� ��5� �
; -HpME-OWNER-BUILOER OECLARATION �ign with One Branch Circuif . -•,i � C r��r O�
��. I hereby affirm that I am exempt from fhe Eonhactor's License pdditionol Sign 8mnch Circuits �
- law for the foitowing reoson(Section 70.3L5,Business ond
- Pvofessfons�Code): � - - � 0 7.�2 Jr'"�`J
❑ I,as owner of the property,will do tfie work and the Mrsc.Conduits 8 Conductors - -- -
_ � structurs is nat iMended or offered for sate (Section - Other($ee Complete.fae ScheduYe}� , -
. 7044,BusEnessnnd Profeuions Code). � �� �
CONSTRUCiION LENDWG AGENCY - . , � -
�hereby affirm that There is o mnstrucfion lending agency for . . -
� tbe performonce of the work for which ihis permi�is issued PERMIi FEE - (Sub-Total) .
- (Sec 3097,Civ.C.). . � .
� -� P[AN Ct1ECKWG fEE � � . .
. Lender a Name - � �� -
� PERMIi�f55U1NG FEE
Lender's Address - ��r� �
I certify ihot I have reod this opplication and staie thol ihe T07A1 FEE - JV �
nbove intormalion is wrrect.I agree to comply with all Covnry - �
_ - ordinances and-State laws reg�lating EIeNf"real wiring, and . . � -
. hereby author�ze represenhatives of-thisCotrnty to ente�upon � � - � - -
�th above-memio ed properry for inspecrion porposes. SEE REYERS�FORfXPiANATpRY LANGUAGE
�.'.� �-�.��.,� - -
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