HomeMy WebLinkAbout1656A (9) - WORKERS'COMPENSATIOhI-0ECLARATION 76A6W� 10/81 qppl��ATIOi� �OR ELECTRICAL PERMIT ��
. 1 hereby offirm tFwt 1 have a certificate of consem to self CE-� ..
insure,or a certifimte of Workers'Compenmt�on Insurance, COUNTY OF LOS ANGElES BUILDING AND SAFETY
-or a�ertified copy thereof(Sea 3800,La6.C.} - . � �
- Policy N�'��77d(1S(1 Eampany- ���-� �FOR APPLICANT TO Fllt IN � JOB �
- - �erhf�ed copy is hereby furnished. New Residential 81dgs. Pools ��H NO. . FEE ADDRE55 ' _ •
1&2-Famil .F � — S LOCALiT -� .
Eenrf ed.copy_is filed with the county bultding inspec- Y•54�
� -- �NEARFST
tion department. - � �� Multi-famify Sq.P1. —
�- - u � -Residentiat Swimming Poals CRQSS 5T.
� Date ?-��.r-Q� Appliwnt. �NY,Y_t+'F: FT�Y•['RT � aWNER OR - �
FIRM NAME� �C
- CERiIfICATE�OF€X€MF710N�F{tEQM-WORKERS' putleis:Rec_Light_Sw._ '�'k - �
� COMVENSATION INSURANCE � . nDozE
Fint 20
. �� (this s�cllon n�d�rof#w cempkfad Ff Mo week Invelr�d by -Totol No. Additional CITM Bar Ta�.N'618-96?-95 1
ths pQreNff It fur wue�IW�drad do4krs(S100j-or le�s.}� .
. I certify that!n Ehe.performance of the work for which this _ VIAPtCMECK --�"
� permir isissved;�IsMaff not amploy�any persorr-inany-manner� - �M .
� so�as io hecome wbject to the Workers=Cornpensatianlaws. tighting fixtores First 20 A�DRESS � �
� � � � . � . Tatal No. AdditFonal .
- 6ofe Applicant �� - . qTY TeL t3o.
� NQtICE TQ APPIICANi: If�, ofter makin �ihis Certifico�e of F�xed Appliances Nof Over 1 HP pERAM1�T
Eaemp�ion, -you should bacome subjed to�the Workers' Range_.Heale�_D.W._ p'����'NT � �
- . Compeawtion provisiorn aE-the�-iahoc-£c�de;-ya�-.eiusi�.fflrth-� � Oven _pryer _W.M., ADORE _
with comply with�sucFti-provit5ans-�w-this--permit-akatl be . Top __._FAU -___W.H.-� � �
� deemed-revoked. � �-- Hood �Pan _peher_ CIiY TeI.No.rJg1�6461
� � IICENSE€?CONTRACTORS DECtRRATIQN ���E��pp
. t hereby�affirm 4Fwf k am licensed undes.prnvisions of Chapter 4 Disp. _Room Air Cond. � REG.NUMOER � � Class _
� (cammenctng wi�h�cYron�700U}c>f I?ivisio�n 3 of ihe Bcvineu Power Ap�roFus 8 large Appliances 6{STRIGF i+f0. PROCESSE6 BY Y
.. - and Professions Code,uadmy Fice�se rs in-EvN#nrceaudsNect � �v Q
� . . � Size&Type HR,KW,KVA,or KVAR�
.. Licertse Number Q�Q.�dR Lic.Cla,�`-a� . Up ro 1 incl. ftNAl . . V
� . N.lpt+(-ri[�al . Over 7 to l0 fnd. DATE �`__� O
Contraciw Date 7-Z-��. ��' - YAL{DATIpN
❑ _ _ Over IO to 56 End. . F�.
FINAL
I am-exempt under Sec. Over 50 to 100 tnc.- BY ��.�1,_ uVi
��� 8.8F.C.for fhis reason Over}06 � �
N
_ - �f�. Services,.Swbd.,MCC&Panel6oards �� . - �
. . � Q-2(q Amp.Under SW V . �
. .. Signature _ 201-}OQO Amp.Under 606 V � � �
�- �� €xemption for Reg.Mair�t Elect. C)vec IQOQ Amp,or Orer 600 V � - z� 6 r,1 6 A �
, ._.. _. . . . _.__._..._. .
. SI[iGLE FAMILY _.._ . . ... . ._ .Temp.PvwecPole-BAppurtenar�es-._- -.._ _.._. . �r�'� 2
----- ----. ..---
• .�,. �
- - HQMF OWNER-BUILDER QECkARATION gpgn M,�iti Ona eranch Circuit - -
� t hereby affirm that I om exempt from theConeractor's license - � . � • � a��O �
- Cow far the foltawing reason(Setlion 7031.5, Business ond Ac#dHRono#Si9n eranch Circuits , � �
� Professions Code�: � - � � � ������
. ❑ I,as owner o f t he proper ry,wi l l do t he wor k an d t he Misc.Condufls&Conductors � . . � _
! . strocture is not inrended or offered for sale(Section - Ofher(See Compfete fee$chedule}_ � 0 7,2 5-8 5
-� 7044,Buskness and Professions Codej. _ . - �
� � C6NSFRUCiION IENDIN6 AGENfY � _ . � . . �
-. I hereby affirm ihat.there is a wnsiruction lending�ogency for .. . . _ --� �� -
the performance of the work far which this permi�is�issued P(RMIT fEE (Sub-Total) -
. (Sec.3047,Civ..C.). . . . . . .
� - PIAN-CHECKING FfE - � . .
� � tender's NarTte - - � � � - �- - - �
�`�_.� .. .. . .. _. � -. .P€RMI7-155U1NGF�E_ ______._ ._._.---.__ ___. _ .
. . . _� .. -_- .-._ -.._ _..._ .. . _ _ . . . . .
;� Lender's Addresg---� - - � .
- 1 certify that f Fwve read this appticaliorr ond state tha��the . fflTAk.FEE - � . . � . . ... .. . . - .. - . �f.� - -. . . . . _.. _. .
. � above informolion is mrrect.I agree to tomply witli aU County . . . . --� .-- -. -. - . . . .-. . ..- - . . .
ordinances ond Sta�e tvws_regulnting Electr'�cal wiring;and� � - -
-�-' bereby authorize-represeNa�ives of thts Counry to emer apon � - - - --- ----- -�=-- ---- - -� '� -_ . .. ..
_--- __
_. _
_._- -----_.
the ov¢-menti�praperty-for insPec_tioa purpases. .... _ .. . . _ .-- . ..
[�� f�'� -- SEE-ttEV@RSE�ESIt E3Ei�EANAiE?RY LANGUAGE -
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