HomeMy WebLinkAbout1685A (10) - WORKERS'COMPENSATION DECLARATION �6A663 �a�8� APPLlCATIOM FQR ELECTRICA! PERMfT � �
I hereby affirm thnt!hnve q cert�ficate nf cnnsent to self . �"�
insure,or a certificate of WorEers'Compensation Inswance, . COUNFY OP LOS ANGELES �BU�LDING AND SAFETY �
or o cert�f d7�co y tRereof?(S(ec 3600,tab.C�) - � � �
PolicY M1���ke�blipanY�-�1�,� FOR APPLICANi TO NLL IH JOB � � �
fertified mpy�s hereby furnished.-. ._ ��-: New Resident�af Bldgs.8 Pool ��� M1w� PEE A�DRESS ' '
• ` �ertified copy is filed�with the�county 6uilding inspec- )&2-Family.Sq.Ft_�_ s�� —�t �OCAEtF �
_
f � �.tion dePortment : . .: .. b{ulti-family Sq..H. -- — NEAREST��. ..; __ . . .
i �p�' ... . .R � .�.Residential-S.vimm[ngP�l:._. . ._. . --. .._.., �t0555T .„�__.., ....._
� Date�jp�Stal_Applicant - - -.. . . - OWNEROR — . ..- .
. . -, . _ . .. F{RM NAME
' �.'.CERTtf1G4FEQFf7fEMP7fQh#.F1tOAti1NQRKE&$'�.,.,..-_ Oudets:Rec_tight_Sw._. .. ..,MAIt... _ .. . . ..
f �';- .:COMPENSATf�M11.fNSURANC€. . ... . .: . - ._ =_. :. .. -ADDRESS- ..: . .. .
i (Th4s Factipn need not be compteied if ing work lnvelved by . firsf 20 - ' . ._. .... -- . �. - ..
F ttw pormif is for ono hundrod dollan(S}(IQ}07 Itw:} .-- �o�{#° ... . .AdditionaT- --_._ _... �_ CffY�-. • � Tet._Na._.. � . � 41
. _ .. ... _ __ plqN CH�C - .,- . . _ .
; 1 certify ihat iro the gerfnrmance af the work for whtch this . -- .. . .--. - -- ���i =.- - . .. . . . .
� permit is issuecl,tshali not eingloy anypersoq in any,manaer .� .': ... ._- _._. _. .. . -- .. .. �
'�. so as to become subject ro the 1Horkers'Gompensotion Laws. �- tighting Fixfures First 20 --- � � App&E$$ - � �
�' ..�... .....�. �.�. � � Total No. - Add'rtiona! �
- E}ate - Applicant -. . qTY . Tel.Na. .
� NOi1fF TO�APPLICANF: lf, after making this Certifimte of Fixed App4iances Not Over i HP _ - ppRp�
Ran e_Heater_D.W._ '4PK�U`Nt ��
€zemptiow, you ahootd becarx�e subject to-the-Werkers' 9 _
Compensatiart�psovisions o#�tke Labor Code,you must fwth- Ouen _Dryer _W.M._ ADDR--
- with camply witfi such�provisions or thfa permit shqtl t>e Top _PAU _W.N.—
deemed.cavoked.... ._ ..... _ _. _- . � . . .. CITY • - Tel.No.
tICENSED CONiRAC7Q€t5 UECL4RARON'. � Hood _Fan _.Qther_ -
- Dis�t. Room Air Cond � ���� C�pu.
. fherebyaHirrtitieai�}amficettse�vnder�provisiam��afi€h¢ptef�.. -" .. — .. REG.NUA48ER� _
� (commenc+rg with 5ecfiorr�7EK7p}0€-{3'rwsion 3�#-tke Busirtess Power Apparatus&Large Appliances . � - DlSTR4CT NO. �� . PROCESSEd BY �
- and Professions Code,ar�d my license Ps in fuH farce and effect . �
I�} 5ize&Fype HP,KW,KVA,or KVAR � Q
LicertseNumber_ ���.:_.l'u.-��}�-�—_ . .(lp�ta-iinct. -.__ ._----- -_. - ------ fiNRt.._ . __ ._ ... ._._ _-..----. .�_
�Contractw�-�--++C 1�%H�--- ��-pnta�� .�er 1 to SD tncl. �ATE k t j t_ ,� e� . VAUDAiiON - �-
Over I�b 50 Incl. F ir
FINAL
��`i.dm ezempf under Sec. " � Qrer.�b t00 lnc. � BY - . - u�i
- B.&P.C.for this reason �ef t� . � �
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- - - Date: - ��vices,Swbd.,MCC 8 Partel6oards - - �. � - . . � � Z
� . 0-20Q Amp.Under 6Q0 Y � .
� Signohire . 2(}1-tOpQ Amp.Under 606 V . �t b�r-J A .
Over 1 WO Amp.or Over 60Q V
�� � Eacemption for Reg.Maint.E�ect. . . - - � - . . - �r s �s a �G� �
51NGLE FAMILY Temp.Power Pole 8 Appurtenances
. HOME OWNER-BUtiDER OECLARAT�ON Sign with One Bronch Circuit � ! � � � �'�a
1 hereby affi�m thai 1 am exempt from tfie Conhactor's License AdditianaE Sign&anch�Circuits � � a�. •7 j,j �
tow fw fhe folbwing reason($ection�703L5, Business and - . . � . �i
Professions Code): � � �7 2����J
. � � I,os owner of the property,wFll do thg work and the ���'Canduits&Conductors - . .
struct�re is not imended or offered for saie (Secfioo 01her(See Complete fee Schedolej-
- 7044,.Business end Professions Code}. � -
� � � CONSTRUCTION LEND4NG AGENCY - - - - � � -
I hereby affirm that there is a co�shuction lending agency for - .
the performance of the work for whicb this permit is issued � PERAM1IT FEE - (Sob-To�ai)
� (Sec.309T,Civ.C.j. , - .. �
� - - . � PLAN CHECKING PEE �- . . .
�ender's Nome
PERMIT 4SSUING FEE - . a . - . �
- �endei s Address �
I certify that i hpve reod this applitmion and state that the T6TAL FEE . � �
above information is mrrect.I agree to comply with alI Counry - �
- wdinances and State laws reg�lating Eledricol wiring,and . � - - _
- hereby authorize representotives af this Counry�o enter upon . - �.- - �� �
The obove-mentioned property for inspection purposes. _ . - -
���c_,/,..�,�_�� ���y� SEE REVERSE FOR EXPtAP1ATORY tANGUAGE
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� Signaiure of Permittee - �ate- : . � � � .
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