HomeMy WebLinkAbout1687A WORKERS`COMPENSATION OECLARATION 76A663 ,o,a,- qpp��CAT10M FOR ELECTRICA! PERMlT - �
� I hereby affirm thaf I have o certificate of consent to self � CE�06G�
inwre,or a certificate of Workers'Compensation ins�mnce, COUNTY OF LOS ANGELES BUILDING AND SAPETY
� or a certified mpy thereof(Sec.38Q0,Lab.�C.f � ._ - . .
P❑ol'�cy No.C'-77��Q�I5�1"'omponY_� � . FORAPFUGNT 70 Flll IN �. . - . .. JOB . . .
Certified�copy�s hereby furnished. New Residenrial B(d s. Poo -�-��-- �:-- . .�E... A�oREu. . , (p .
�. '� .Certified copy is filed-witke the cou�ty building-inspet- .1 8 2-Family,Sq.ft-�� ; � --- S � LOCALITY . �
tion depurtment.� - - ��� - � - Multi-fnmily Sq.k. — NEAREST
x p ResideMial Swimming Pools ��`ST.
� 'Date '�--.—?�-��—Q�APplicant. T h'Yf'� F.l�r+ri � . OwNEa�tt � .
� . � fIRM NAhVE
- CERTIFICATE OF EXEMPTtON FROM WORKERS' putletr Rec„Light_Sw._ - - �'�F� -
COMPENSAT4QN INSURANCE ' nooRess� '
(This aaetioo noad no4 6s mmpletod 4E fbs work iwrolved by - First 2U- .
- 7oral No. qcfdikian�t CITY • Tel.No.
tho parmir is for on�bundrod dollars(it00}ar tQs:.) ��� — — 4I
. t certlfy that in the-performante-af�the work-for whith this - p�pp���M�� � �
�, -permit is issued,4�sholl not employ any person in any manner _
sn as to�becorrie subject�to ihe Workett'�Compensation Laws. tighting Fixtares First 20, ADORE55 �
- � � �Totoi No. Additiona! . .
- Dare ePPlicant . .. . CITY Tel.No.
-. NOTICE Td APPEICAIVT: If, af�er making this Certificate of fixed Appliances Noi Qver 7 HP . PERMIT �
Exempfion, yo� should become subject 10 the Workers' - Rartge_Heater_D.W._ . A��Ni�� n
�"" Compenxi�ian provisirnu of the Eabor-Eode,you-musf forth- -Oven _6ryer _W.M.— ADDRESS- � � �
wi�h compty�witM such provisions�or this permit sFall be .:top. ._PAU —W.H.—
- deemed revdced_: � � Nood _Fan _Other� CITY TeE.tdo. _
LtCENSED CQNTRACF6R5 DECLARATION � tICENSE OR
- I herebyaffirm thottamiicertsettvncterpravi3ion3 of�Ehapter9 � �'�� —Room Air Cond. — REG.NUMBER «• -
-. {comrtrer;cirg wi�h Secliwr-70fp$�isf Divisiorr 3 csf EHe-6usiriess Power Apparafus 8 targe Appliances � DISTRICi NO. - �� PRO�SSE�BY y„
. nnd Frofessions Code,a�my license is in full�foree ond aEFed. -- �
� � Size&Type HP,KW,KVA,or KVAR - �
�;-� License Nvmt�r d7t}�dF3-. .tic.Ctoss C=-1f1_. .. Up to�R inct:�-� - FINRL � � V
�, . . Over 1 to 161nci. �TE ` `�'1 `-.��+ YAtIDATIQN �
Conh«t« F.121"�ri nal- Date �-12—RS- �1` ____ O
O � Over iQ to 50 Incl. - 1�-
FINAL
. I am ezempt under Sec. Over SQ to 700 I�c. BY � �- -W
&.&P.C.tor ihis reasan- �v��� 6
- �a�e. � Servi[es,Swbd.,MCC 8 Vanelboards . ►_
Z
- . • - 0-200 Amp.Undar 600 V � � � �
Signature 20l-t�0 Amp.Under 640 V . � `�(��'7-� � �
� ❑ , O�er t00Q Amv.or Over b00.V � . � �
Ezemption for Reg.Mainc Elect. - �� � �2
. . � SINGL€FANtILY - Temp.Power Pole&Appurtenances
HOME OWNER-BU�CDER�ECLARAAON � Sign with One Brunch Circuit ' � �6$'� �
_ 1 hereby offirm thw!am exempt from the Contradw's License Additianal Si n Branch Circuits - • m m `
. law for the fallowirtg reasort(Sedion 709L5,8usi�ess and . 9 ... . �� � t����- .
Profeuions Coda): �
,,, �� Mizt.ConduEfs 8 Canductors � - Q��2�`�a
I,as owner of the property,witl do the work and the
structure is not intended or offered for soie(Section �tber(See Compleie Fee Schedule}_ � - -
7Q44,Business and Professions Code). , � -
- � CQNSTRUCTION LENDWG AGENCY � � -
� I hereby n£firm-tVwt there is a constructioa Cending agency for . �
the performflnce of ihe work for wbich this permit is issued pERMiT"FEE �� �� -� � (Sub-Total)
� (Sec.�47,Civ.C.�. � � . - . . .
. . - PLAN CHECKtNG FEf �
. Lender's Name � � ^ - .
. � PERMIT ISSUfNG FEE � -� U �
Lender's Address �� � �� �Q .
I certify lha�1 have read ihis appiimtion ond state that the TOTALFE€. . ___ . .� �
above information i:correct.i ogree to comply wirk all Coony � -
ordioances and Stute laws reguloiing Elecfrimt wiring,and - " � -
� hereby oWhorize represemmives of this Coun�y to enfer upon . � . , _ .. . - � - . -
� tbe above-mentioned properry�Tor inspetrion-pu�poses. - � � �
� �7 ��� ������ SEE REVERSE FQR EXPtANATORY LANGUAGE
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