HomeMy WebLinkAbout1670A (10) - WORKERS'COMPENSATION-DECLAkATION � 7M663 loi6t �ppllCAT14N--�FOR ELECTRICA!�PERMIT�� � �
� 1 here6y affirm that I have a tertifimte of consent to self �"� � � �
insore,or o ce�tificate of Workers'Gompeasa�ion Insurance, COUNTY OF lO5 ANGELES BUILDING AND SAFETY
or a certified copy ihereof(Sat.3800,Lab.€.) � .
P�of'rcy No. r�h?�'t.���B°mP°�Y ucr--- . . . wR AWtKAM7-TOFIkI.fN _'._._ . �pg .. . . .
Certified copy is hereby Eumished.- --� � New Residentidl Bidgs.8 Pools --�� - �•� --�---FE6�---_- ADDRESS ' •
�.sa.Fa,T,�i -Ft.1775 s_ --s �ocnurr .
. Certified capy is fited with-fhe-eotiniy buitding inspec- Y,s4. "- ' . -
�j 1ion�deponmgnf. .... � � . . . Multi-famkly Sq.H. � — NEAREST .
A� �i Residentiol Swimming Pools ��R��_ � -
�ate� '�—_.y—��_Applicant-�� - � - �
FIRM tJAAAE
- � � CERTIFICATE-6FEXEMPTC6N'FR6MWORKERS��- � - ._-- �MnY�
� COMRENSAiION INSURANCE - � � Outlsts:Rec_ligfit_Sw._ ADDRESS
- ----- � -.._�_._ .. first 20
Ethtt�et,+""",t"°T�°'°"'�t�t€�"'°d��Y'�'m�t tr�r Tolol No. Additionai cETM D- Bar rei.N°8I8-96 —95 1
+�o�cr�.�.�.►w�a..�d4���,tswo��a...►
�� 1 cert'rfy thot in the perfrnmance of the�work#w-whkh this - q�N�ry� �
-- pe�mij)s issued,�t.shall not employ any persan irt arty monnee-- - � � . . �
- so bs to become su6ject to tke'Warkers':Compeniatian faws. Lighting.Fixru[es First 20- ADDRESS
. . - �.-� - � Toral No. �ditlonal
. . aoplicant . CITY ieL No.�
Date Pized Apptiances�Ftot Over 1 HP pERM�T
NOTICE T6 AFPLICRNT:lf, ahermakirtg this Certkficate of APPUCANF �� �
� � Exemption, yau..shautd..6acame..wbjecf-ta--the Warkers' - Ronge_Heoter_D.W. — ' .
Compensotion provisiaas of tht ta6or.Eode,you muzt-forth• Elven _Ehyrer _W.M.— ADQRE55 P�Q� �X ,�111 ��
-- wiEb comply with such provisions or this permit shatl be Top _FAU �W.H.— . . �,
� deemed revoked.�.. ._..._.. .. _. . CITY . Tel.N '�
CICENSED CONTRACTORS�KIARATION � H� —Fon _Other_ . — 'i
. � I t�reby.aff'�cm fkai 1 om liceneect vnder proyisionsaf GhapYer 4 Disp. _Room Air Cond. — �t�G.�NUh�BER� Elass _ I
..-. [commencing vritt+-5ection-�7IXaf}}of�Divislorr-&e€-iMe-6nsiness- DISTRKT NO. ! PROCESSED BY �
�E Power Apparat�s&Large Appliances Y �
- andProfessiflnsCode,�crrd�#icenseis.in.fti}f.force�and�ffect. { d- y j
� - . Size&Type NP,KW,KVA,or KYAR� � 4 �
ticense Number a�Q�QA -- tic Gnss ('--1(} RNqI. V
. Up to 1 fnci.
.. .. .. . Qner 1 to 10 IncL QATE .� �^ r.,�� ct
� Contractor ��''-1 Er!'t'i[�al po�e 7-7���$� ��' 4`f ALlDATiON . . - Q
_ Q : - Over t0 to 5(1 tncl. FINAI ~
1 am exempf under Sec. Over 50-to 1�0!nc- 8Y �
8.&P.C.fw ihis reasan Over TOp Z
� - $ervices,8wbd.,MCC&Purrelbowds � �-
.. . Date:� 6-200 Amp.Under 60D V � � �� 6!�Q A� .
Signa�ure - 2(Fl-1000 Amp.Under 600 V -
.. ❑ .. Over 100Q AmP,or Qver 600 V � . �� � • • �'�
. . €xemption Eor Reg.Maint.€lect. ' + • •�.�.�a
-. � SWGLE FAMkIV ?�p,power Pole 8 Rppurtenances
- - HOME OWNER-8UllDER DEfLARATfON Sign w'tih One Brartch Circuit •• `S�.5 Q�_
- I Fereby affirm that l am exempt from the CoMractor`s License q�}ditional Sign Branch Circuits - � .,
�-� Lnw for the-fatkow'�ag reasan f5ectian�7031.5, Business and Q 7��j•-8�
ProfeuioruCode}: - �
-❑ I,as owner of tbe�property,wilt do the work and the � ��sc.Conduits&Conductors � �
_� strutwre.is-not intended or offered for-wte (Seetioo Other.{See Complete Pee$chedole}— ► � .
7044,Business ond Profeuions Code). .
, CONSTRUCTION LENDING AGENCY - - �
-- 4 here6y affi�m ihat there is a construction lending ageocy for � -
the performance of the work for which Ihis permit is issued p�RM1T FE€ (Sub-Total} - � .
. {Sec.304T,Civ.C.�. . � . �
� PLAN CHECKING FEE . . . ._ _ �
Lender's Name- � -
. � . PERMIT.ISSUING fEE
Lender's Address � -
1 rertify.that-_I.have reod tfiis app(imtian.and stote that the �. � TOTAI FEf. � -__......_._:_ . .$�..�JQ _.
- �above infwmafion is corcect:I agree to compty with af!Co�nry -��-�-�.-�--- -
ordirronces and State laws regulaling.Eledrical.w'ving,and _ __;.-__ _._ - - � :_ �. - . . � �
-- _
hereby authorize representafives ot this County to enter upan .
the bove-men[ioned praperty fw mspection purposes �_ � �-- ��-- � ---- -�- -- -��-- - � .
SEE REVERSE fQR$XPlkPtATORY LANGUAGE
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