HomeMy WebLinkAbout1684A (10) � WORKERS'COMPENSATIONDECLARATION 76n6a3 t0i8i qpp��CAT10N FOR ELECTRIC/AL PERMIT �
� - 1�hereby atfirm thot[hove a certificote of consent-to self �-�
- insure,or a rertiticote of Workers'Compen�tion Insurance, � C�UNTY OF LQS ANGELES - BUILOING AND SAF�Y
ora certif/ie1d�c}og�y'1tfh(�erfeLo�yf($�ec.�8Q0..la/1b.��G].)- - � .
� Policy Ndi.�$c'�(�i�•l,npany�/1(� —_ - FOR APPLIGNT TQ FLLl W .IOB ' �
�. Cerfified copy is hereby�Fvmeshed. New Residentiol Bldgs. P� � EACH � NO. fEE AD�RESS
�ertified-topy�s filed wifh tMa munty build�ng inspeo- 7$2-Fomily.Sq.Ff. s — E L6CAU
. �kion deportment, -- ��{�� I . Multi-fam4ly Sq,fF. � � CR�p58 ST. �
. Dote_.`iC���Appli€4nt 1 I�� Residential Swimming Pools OYlNfR OR - .
. ___ _.._ . FIRMFIMAE
CERTIFICRTE OF�EXEMPFION ERQM Y�4RKfRS`.-. � MP,iI � .
C6MPENSATION lNSURANCE . � �otfets:Rec—(ight_Sw._ .- ADORE55 � .
This sqction aaad iwt 6a c �iF tha�wotic Mrolvwd First 20 � _ 1 I
( � �@��E°a �' Total No. �CITY . Tel.N
tho parrqlF 4s�►or one h�ndrad deNoa(Si6_0}�or tess.}: Additionaf _ _
. 1 certify thot irt the performance of the work far which this - - - APPLNCANT .
.- permii is issued��i-shall nnt 6mptoy tiny-perann�Tri tiny rtwnner -. .
so as to become subject to the Workers'Compensation Caws. Lf9hting Fixtures first 20 ADDRESS� � �
- ___ ..------- __---_ ___... ___.. ... __ _ Additional.
...- ...Total No. tITY Tel.No. -
- � Date a.,.^.Plimnt . .. - Pixed Applionces Not Over 1 HP pERMIT- .
. NdTICE-TO APPI.lCANT:-ff,--afrer moking"this Certifimte of Ap���T n rt
Exemption, you shoutd becbme-subjecl-to the Workers' Range_Heater_D.W.�
Compenxition pro�isiona.oF the Labor Gode;yov-mu�-£oHh- �ven _Dryer _W.M._. ADDRE55
with camply with such provisions w this permit shall be 7op _,�FAU —W.H.�. ,
- deemed reuoked. -- -, . H� _Fon � _OtM1er� CITY . � Tet.
uc��a cc3riraaacuzss€€Fnrwr�or� u�Ns�oa
- 1 here6y effirm Hwf I�em#ieemecf ortder provisirnrs-ofiEhapter 4 Disp.� _.._..Raom Air Co�d. —. REG.NUMeER � � Ctass _
�-� (commencirtg with Section 7WQJ of Division 3 of Jhe B�niness � - DFSTRlCT NO. � pRQCESSED BY
�n Power Apporatus&Large Apptiax�s- � � }
- �ond Professions Code,anzl my litense IsSn full force ard effect. � - 0.
y��y Size&7ype HP,KW,KVA,or NVAR - . O
.� License Number��•,�,_Lia Ciass�� .. - . � i.F
, Up ta 1 IncL FINA€
Contractoc��ELeLs���Date��.$,Z_ Over i fo 10 tncl. �� .:..l-`�"�.P- VAtiDA710N - G
QOver 10 ta 50 fnd. E4NAL - ..
i om exempt under Sec Over 5Q to 1(iQ Inc. BY � �
- 8.8P.C.4or this reown � Over IOQ � H
� . Services,Swbd.,MCC&Ponel6oards � - � z
- 6ate: 0-200 Amp.U�der 6pQ Y - - � - -
_ Signdu�e 20t-IOpQ Amp.Under 600 V - -
� ❑ . ,Ove�t00Q Amp.or Over 600 V . e] (;$/j(?
E:emption for Reg.HWinL EFect.
SINGLE PAMILY � Femp.Power�Pole&Appwrenances #��� � � �.�
HOME OWNER-BUILDER DECLRRATION Sign with O�e Branch Circuit . �.��'7� 7 Q
I hereby affirm that t am exempt from the Controcto�'s License Additionat Sign Bronch Circuits �
taw far the following reason(Section 7037.5, BusMess and � .� - --- � - z -
� � Professions Code): �
• s �7 I.(Q o
- � ❑ I,as owner of the ro Misc Condui�s&Conducrors- -
p perfy,-witl do ihe work and tfie p�h� �e Com lete Fee Schedule_ ��,2 5—�5
stracrvre is not-intended or offered far wie(Section � P ) �
. 7Q44,8usiness and Professions fode). . - �
.� CONSTRUCTION IENDWG AGENCY � � . � � -
- I hereby affirm that there is a construdion lending agenry for
� ihe performance of ihe work for which this permit is issued - - PERMR FEE (Sob-Total) � -
� (Sec 3097,Civ.C.). . _ . . . .
� � - � - PLAN GHECKiNG fEE � . . - .
.- Lender's Name - � In
� - PERMIT ISSU4NG PEE /��
- - Lender's Addreu � �
�certify that 1 have.reod this applimiion and stote ihat the� TOTAL FEE . � � _ �
above information is wrred.I ogree to campiy with all Counry � . .
ordinances and State lows regulating Eledrical wiring,and �
� hereby authorize representatives of this Counry to enter upon � � �
. Ihe above-mentioned�aperty for'nspection pwposes. � �
SEE REVfRSE fOR EXPLANATORY{AP/GUAGE
_�,_9 0�������r�° _ - ___ _ _ _.
SignaN�e of Perrnitfee � � Date � �
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