HomeMy WebLinkAbout1690A (10) �WORKERS'COMPENSATIpN DECLARATI6N �a/+663 ��ie� qpp��CATIQI�! FOR ELECTRICAL PERMIT � �
� I hereby affirm tha�I hare a certiticate of conseN to:self fE�OdG - .
iowre,or o certificate of Wwkers'Compensation 4nsurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
vr a certifl�!dcG�tcqqo the/r af S .38W,La6.Cv)� � - '
� - Polity N6�` meP�^Y�!-�If i0E APPLfCANT TO Flll W - . . ADDRE55 - Z .
_ � �fer#ifiad cap�is hera6y furnlshed. . .-. - - New Residential 81dgs.6 Foo�l/s FACH NO. FEE ' .
' ,,�.j 1&2-Famit R. y 0 .. ��'b'��N
��Q, Certified-copy is fifed with the coonty boilding inapec- Y.$4• f 7 � s — s TR 3558 Dli3JIq
. j'� fian dC�epa�rlmpe'�nt. �� Mulfi-family Sq.FL . . CROSS ST. L� ,7V
Oc�fe�(2L0.�1..AppliwM� ������ Reside�tio)Swimming Pools - OWNER OR �
F RM NAME
- - CER�IFICATE OF EXEMPTION FROM WORKERS' O�ffeh:Rec_Light_Sw.� ��« �
� � fOMREPISAFfOW WSURANCE - � - nbokeSS
(Tkia aaefba eaod nof be eampleted Nlhe woek invokved bY Firsf 2(t .
. tha parmit is 4w ons hundnd dollors fS16QJ or leca.y� Total No. . Arldifionat GIFY Tet.No. _ _ 4�,
- I certify that in the performance of the work for whick�his . _ - PtAN CHEQC � -
� APPLICANT
.. .-permia is issued,-Faha{I not empfc:y c�ny persars irt aey martner- . . �
¢o vs to 6ecomc subject in thb fAForkerS-tompensa#ion£asvs. Lighting Fixtures First 24 A�ORESS-� -
� - � Total No. Additionaf
Dqre Qppliwnt . CITY � Tel.No.
Fixed Appkiances Not Over 1 HP PERanri
� N6FIC€TO APPUCANT; If, pfter making this Cartif'�ca1e o4 : � n -
. Exemption, yoa'shouid-become-subjed ro��-lhe-Workers'� - Range_Heater_6.W.— ���+H7 r`1' � II�'.�Y7F'RT�
Compensation proviaiorts�of the tabor Gacie;-�yo€rtrtuat f�eh• - Oven _Dryer _W.M.— AppRE$S.
. with compty�wi�h wch prev+s�o�-vr-this perrna'stwtl�be Top —FAU —W.H._ ..
deemed revaked. � - � - CITY • . Tel.No.
- _ .LlCENSEB CQNT&AC74R.�DEGLARAT!£JPk---- �� . Hood _Fan �Oiher— . . �
- I hereb uffrcm that{nm titensed-under �F �Disp.__Room Ai�Cond. _ u�N�� Cla `
y p(ovi5iansvFCho 4 REG.NUMB€R-
(cammeracing with Sec#�on-70f14}cs€�ivisien�3 of the$usiness �paWar Rpporatus 8 Large Appliances . ��ST����a- PROCESSE6 6Y �,
� and Ro€essions Code,and my 4icense is irtful4#orcennd effect. . � (� O
..._- c�)q��j �--� /Jy Size&Type HP,KW,KVA,or KVpR - (
� License fH�mber��y,�J�//7„�lic.Class � [(f . . . ,. � . � . V
��( Up to 1 Incf. - FlNAL--- t `
. . Contractor��-L��-- Date__�� - . �'er 1 to t0 IncL ��TE �� 1�`�a/ YALIDATION Q
� _ . Q�er 10 to 50 tncf. f4NA � _ � ~
1 am exempt under Sec � Qver 50 fo t00 inc. 8Y . uVi
� B.&P.C.for this reason Q°a`�� 6
H
�� Services,Sw6d.,MCC 8 Panelbaards - � � 'Z—
Date: : O-2fIQ Rmp.U�er 5W V . .
-� $Ignature � - 2(!1-lOQO Amp.Under 600 V - � �
� - � � - � Over f 000 Amp.or Orer 600 V - �
Exemptkuc-for�&eg,-.-nsa„uu.€recy;-.- � <7 6 4`,Q S
� SINGIF FAM1[Y � Femp.Power Pole 8 Appurtenances . #e-m • • ��
+. HOM€OWNER-BUtEDER DEC€ARATION � Sign with One Branch Circvit .
� I hereby aHirm that 1 om exempi from ibe Confractor's 4�cense qddifionol Sign 9rartck-£ircuits---- -- -�- � • e�'i B.�{Rj
Law 4or rhe fclfowi�g reason(Section 7Q31.5, 6usinew ond � �
Professions Code): �
- � Miu.Condui�s&Conductors � . . 'p `b"'� �"
I,as owner of the properry,will do the work and the -
� shucture is not intended or oHered far sate(Sectian �+her(See Complete Fee Schedulej_ � O'J 2.v—8 rj
- 7044;Busineu and Profeuions Code).
� - CONSTRUCTION LENDING AGENCY - _
- I here6y affirm that ihere is o tonstruction lending ogency for .
� iF�e performance�of the work for wfiich this permit is issued � PERMIT FEE (Su6-Tototj JY
. (Sec.3647.Civ.C.). . . .._. -. .
. . . ._ _ __...... _ .. _.
' - ' PLRN�CH€CKING fEE - � -
Lender`s Name � �-
'. - . � -- �PERMfF ISSUWGFEE -� . �(�.
� Lender's Adctress . . .- . . � � � � -
I certify fhat I have read fhis application and state lhaf 7he �OiAL FEE . -
a6ove informalion is correct 1 agree to comply with all Covnry . . „ , ,
ardingnces and Stote laws regulatirrg Electriml wiring,and �
� here6y avthorize rep�esenmtives of lhis County to ente�upon - -
� the o6ove-memioned property far inspection purposes. - � � - -
� ���7��' ����/�6� SEE REYERSE POR EXPiANATORY IANGUAGE
- Signature of Permil�ee - � --Rc � pote - - � - -
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