HomeMy WebLinkAbout1655A (9) WORKERS`COMPENSAT101V.DECLARAF40N - -- 76.4663 tWBr /� - '
� 1 hereby offkm#Fwl I have a cerhf�cate-af conSeM to self�.:- �CE�06G� . . r1PPLICAT10�1�-�C?R-�-��LECTRICAL PERMIT�- - - �
insure,or a cert�tico�e aE lYorkere'Cuaipensvtion:tnsurance; COUNTY OF LOS ANGELES Bl11LDINCe AND SAFFTY
or asertified coQy thereof(Sec.-3B0p,-lab.-E.)�
Policy Nd'-�nTdnS(1 Campany.��:-����n _. �. FOR AP�tKANi TO HLL.IN . �D�� � . . - I
ertified cCpy is hereby furnished. - � New Residential Bidqs. o Is — � �`CM NO. fEE
t&2-Famil F s — _ ��
� ,Certified copy is filed with the county 6uifding inspec- Y.59•
fion department. - . � Multi-family Sq.Pt �NEARES .
- n u- Residsntio!Swimmi� Pools CRO55 ST. �
Date 7�22^$rJ APPlicant `r. 1�'E@ '��.eG'�Y'1G` 9 QWNEROR
� FIRM NAASE--
- CERTIEtCATE 6F EXEMPTION FROM WORKERS' puttets:Rec_Light_Sw._ 'Y'a'���
� � COMF€NSATION INStJRANCE � ADDRESStQ�I� PdTI{-V12W U.0 ZOI
� - - � iirst 20 � .
(Thi�txtion na�d.nW 6s cumptstad iE�-th�work Inwilved by- Toial No. Add�tio�ol - � GTY • � Tel. — _
_� iha p�rmif ts(or oen hundred dollar�'(5i00J or I�as.) � PtaN cHECK
f cerrfy itiet-in rhe perfermance of the-vrork for whicl+this - �� qPPI�CANt -
I permit ii issued,-!s#colt not emptog-any person in oriy manner � .
. so os to become subjecf to the Workers'Compensation Laws. Lighting Fixtures Firat 20 ADDRESS
.. .. - . -Total No. � Additional
- .. ClTY Tef.Na.
Dote � �+pplimnt - - � � Fixed Apptiances Nat Over i HP PERMtT -
NOTtCE Td-APPLICANF: lt,�after moking#his Certificate af qpp�E�p,ry�q ti �
. Exemption,y ouu should 6Q4pme:�--subject.ro..the:.YVwkers' -- --R-aage.�,_Heatec_Q,�Y.� . � � ' ��
� Compensation provisions o#�lhe Labor fr3de;-you must forth- Oven_Dryer _W.M.— ADORE55 .
-� wifh compty witfi such prorisi6m or tFtis permit shaii be ._._ .-Top- ...��6AU _-aM1F.H.�— �
�deemed revoked. - �- � " ' E�TY . - Tel.No.
� .LtCENSED GOAIIRAETORS�EC-kARA;lE3N- ff�� —.Fon -_Other� . - - � —
. . - .U� Room AirLond. � uC€NSEQR . G
. 'ihereGyi�£f'nrrr-thattam-licensed-vnderpresvis����aftfiapter9..��.�. �--:— REG.tvtlnheFR _
(csxnmerKiny wFth Seetiort 7Q4D}..of FJiuision 8-af th�Sosi�ess Power Apparotus 8-terge Appfiances � DISFRICC NO. �d PFC(10ESSED BY }
and ProfessiQns Code,and my k"rcense is in fut4 fwce and effeeF. - ... . . - 4
- . � - - .Size 8 Type HP,KW,KVA,or KVAR 4
Licensa Num6er Q�n7d$- Lic.ClassL'��Q- � Up to 1 trtcC FlNAL- - u
EleCtriC�t 7-22-85 ove�}ta ia��d. ontE ��-t�-,-�� vauoanoei °C
. Contractor Dafe . Qver 10 to SQ In<l. � - � V
.. � t am e+�empt under Sec. - Over 50 to}90-lrfc. BY��/ . �+ �
� � B.BP.C.for tbis reqson 4ver l OQ . . . . 1aI}
� Sarvices,Swbd.,MCC 8 Panelboerds � , � _
_ Dase' 0-20Q Amp.Under 600 V � - �
� .__ Signoture - 2(71-1000 Amp.Under 600 V � . ��b�5{�
_D -��Over iCUQ Amp.br�Over 600 V - ..
Eaemption for Reg.Moinf.Elecf. ���*� � �2
SINGLE FAMILY Temp.Power Pole 8 Appurtenances � - �1�O rj,5 Q
. HOME OWNER-BUILDER DECtARATION � Sign with One Branch Circuit
1 hereby oHirm that I om ezempt from the Controctor's Ficense � - � � - •-� �(���O?
Law for the following reoson(Section 7037.5, Business and AdditianoF$ign�8rancfiEvcuits-� � _ � .
.. Professians Code�; . - �
� � � � � Mist.Conduits&Condteet€xs . � - � _. Q�.2.�7—.S.rJ
1,as owner of the p�operty,wilf do the wQrk ond the t .
-. � strudure is not intended or offered far wle(Sedion Other(See Complete Fee Schedulej_ � �
_ 7044,Business and Professions Codej. . .
CDNSTRUCTION LENDIPtG AGENCY - � .
1 hereby vifrcm that ihere is a conshuction lending agency for .
�f�e performance-of ihe work for which this permit is issued � -� PEftMR FE@- - (Sub-Total�
� (Sec.3047;Civ.C.). � � �
. . � PLAN CHECKING FEE � � . � . - _.
. Lender's Nome -
- � -� PERMlL755U4NG FEE - . � �
Lender's Address � � � - .
I ceriify Ihnf!hove read tbis application and stote thot the - � �L�TAL FEE �
above informatfon is correcL_t agree to�comply wifh�olt County - - . �
ordinancea and Stafe-laws regulating Electrical wiring,and .
here6y outhoriZe.representafires of thiz.Euunty to euter upon- - � � .
thep6ove-menlioned property#or inspectto�pwposes. SEE REVERSE FOR EXPLANATQRY LANGUAGE
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