HomeMy WebLinkAbout1689A (10) . ��. WORKER$'COMVENSATlON DEMRATIOEJ �- - 76A653 16/81 �PPl�I�ATIt�I_�1 FUR �LECTRI�A1.;-P�(� �� �
� I hereby aHirm rhat i Frove a-certificote of consent to self�� Cf�on� ._ _ � __.�.
insure,or a cerf6imte of Workers'Compensation tnsurance, C�UNTY OF LQS ANGELES Bl71LDING AND SAFETY
� ar a certified copy thereof(Sec.3600,Lab:C.} - . - -
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' PQolity No. �7�]4QS�mPp�Y 1TT21 �. _FOfl APPIICANT T4 fUl IN � � � JOB _..._ . .... -. ._ _ _ _. ..
.�Certified mpy is here6y furnished _ . New ResidentiaT 8idgs.$P � � �' " �� Ao���
� is Eiled with ihe coun buildi �7� T B 2-Fam�ly Sq_ft^;���� . ' _ LOCALfFY . .
Eertified copY ty ng spec- s -- - _ - �
� �tion deportrrrent, ..�+ � �' ^� Multi-fomJy Sg._FL — NEAREST r� _ _
� � Dote__J�ppptiwnt ! �,�L�s . � ResidentioY Swimming Aools �ST� � . � 3✓. . . .
. : �- . _ _... ......._ _,.-. . .._.
.:�-r :::.., -. FIR1J NAME -
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. . �_' CFR7tFIGtEOFEXENfPFIi7Bf-fB4dAibIQBK£R.5`=_. _' _. � 6uilets:Rec_�ight_Sw.._ .. . .-._. .__. ..Mnft--- �_ ._.... __ . -
__.CCJMPENSRFtON tN$URANEE . . ..�. . . . - ADDRESS-� - �-
(This soetion naed not ba eom ktal if ttro work inwlvod b ___.. .. Firsr 20 .. - ..
. P Y Totaf No Additional _._. ..__ _ . ._ CIFY-:.-. ._ _-. _-_...._Tet.-Na-$1�-g�-g 4I ...
: eho pmmit fs fm ane 6uadnd doliars{S3p0)or Iss:). _ p�w cHE[�c ��
� . I certify tlwt en.the perfocmarue of 3he�-_vrork�oi.which this . . . . . . . naPUCatar i
� permit is ixsued,i zh�l!ewt eaEploy any penQn ina�p manner . . . �
sa cs to became subjec�ro�}ee�-Wwkers��Gn�npensafion�la+�rs. lighting Fixtures First 20 �-�� ADD&ESS� � !
� ... . .. .. ..... .. . .. ..... Total No. AdditionaE � � ;_
� 6ate APPlicant � CITY Tel.Na �
� NOFFCE TO APPLICANT; If, afrer making-�this Certifimte of fizad Appfiances Not Over 1 HP pEgM�T i� t�
� Exemption, you shoufd become so6jecf to the Workers' Ronge�keater_D.W. _ APPttCAM
Campensotionprovis[onsof the-tabor:Gode,�yosrmust�forth- pven _�ryer _W.M.— . ADDRESS -
with compfy with-such�provisrons--or-thia permit-ahoH 6e Top- _�FAU- —W.H:--
- deemed revoked. . ._... .__.... _ .__,._._ . . � CITY� . Tel.No. �
LkC€NSED CONTRACTORS DEQARATION - Hood :_Pan� _Other— - /�y
_Room-{1irGortd-.__.._ .-__. . . klCENSE OR � Class /Il
. lhecahyaffirm3hut�iam,iiten6edalnderpravdsionsa�.€�atlpter4..�- �`���...- ' — REG.NUMBER
(corome�ing.�.vitV;��ction�ZQ44)af tTir�siart�of t6�:$�ir�ess-- � DISTRICT NO. PR. .. &Y -
_ ard Professions Code,and�ny ticahse is in ferkb ferce-and.effsct. - Power Apparatns&lorge Appliances-� �� Y�
-� /�,,�//� Size 8 Fype HP,KW,KYA,or KVAR�- � � �
_ License Nvmbec �D7��-..aic,Efass�.l.t[:_. � �Up to 1 Fnd. � FtNAt � - u
�i . . �L l_T���G �� Over 1 b FO ind. DA�,,�-t�r ,.'��,"S� � VALIDATION Q
Cantroctor - . :--�e : -.. ....- - Over 10 to 50 IncL .
FINAL ~
� .Q f am ezempt under Sec. � Qver 5�to I�Q Inc. BY _. �. �
. . ., _ .. _.. ..._.._.._ .
� �B.&P.E.-forth�areasoe+.::. .� .. .. �._ Over-106 ._. - :.:- .�. -� _ .. .._ .. .__ - Z
__ _- -- -- -- ._._
Date: � Services,Sw6d.,AACC 8 Panel6oards � � �
-� � _ 4-2W Amp.Under 600 V .
� Signature � 2Q7-1000 Amp.t)nder 600 V � z� 6�.g A
Over IW6 Amp_or Over 60p V
� � Exemption for Reg.Mnint.Elect � �� � -� - #�s � • • s G . .
--- --_ .._-- ------ ------ --. _. _ -
� SINGIE FAMILY � Temp.Fower Pols 8 Appurtenonces
. HOME OWNER-BUILDER DECLdRATION Sign w"�th One Branch Circoit� � � �b�'} Q
IherebyaHirm#hatlamexempt{rnmiheContractor`sticense . qddttionatSign�BranchCircuits - • a s[i,"� _
law#or lhe�followirtg reason(Section-7�3I:5,Busiftess end . - . � . �' ��
� . Professions Code):�. ' - '
❑ I,as owr�eCof the �-wilt do the�wark and ihe � _� Mix.Conduits 8 Conducton � . . . .. . G 7��`�5
��Pef�� O�her See Com lete Fee Schedole_
; sirodvrg_is.not.intendedor,offered.for.gaie(Section . ( P ) ► .
. 7044,Business and Professions Code). � �
� CdNSTRUCTtON LENDING AGENCY -� ._
I bereby affirm thaf ihere is a construcFion(ending agency for .
fhe perfarrtwnce of the work for whieh fhis permit is issued PERMIT FEE (Sub-Totalj
� (Sea 344T.{iv:f�.J.�-, - .
- - � -� PLqN-CHECKING FEE -
� Lender's Name -- - � n -
� � � � PERMIT tSSUING FEE (/ . -
� Lender's Addrass - -
� I cerrify that.t hare read thi;:apP�Ka�ion_and state that the -. T4FAi_f_EE. . . . . _ .
obove informafion is correcl.F agree ta comply wKh�ol4 Co�nty�- -��
. ordincnc.es a[�d Stdte kaws�re9ulqting�Eleclrico{_wiring,ond_. _ .... . :___.
hereby authorize representnifves of fhis Ca�nty to enfervpon - � �
� ihe� bnve-mention properlyfor irtspection purpeses.
���� ,�/ ���� SEE REVERSE FOR EXPLANA708Y LANGUAGE �
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