HomeMy WebLinkAbout1674A WORKERS'COMPENSA7fONDECLARATION �6A663 �QiB� APPlICATIQN FQR FLECTRfCAE PERIIAIT . - }`�
- --I hereby afff�m�that I have_a ceni4icate of-consent to self CEfl0.5G
insore,ora tertificata of Workera'Compensation Insurance, �OUNTY OF COS ANGELES BUItDING ANR SAiETY ��
or a cerNfied copy thereof(Sec.3800,La6.C.} �- � -
P�olity NoC'7,7.7id�iS�lCompony � F04 APPIICANT TO FlLL IN� . JOB . .. .
, -Certi(ied topy is hereby fumished. New Residential Bld���ols �� �� FEE A���
_ �Certitied�eopy is f'rked with-the_county 6nildirtg�irispeo-, 1 B 2-Family.Sq. . f — s LOCALITY ..._.. . .
tion department. . Mulfi-family Sq.Ft. — �NEARES7 �
� H �r Residential Swimming Pools QW R� 3
Date.. '7-77��S APPlicani. T Mr�C`m:_H.l eni-rjy . .
. � . FIkM NMAE �Q
� EERTIPICATE�F E%EMPF40N FROM WORKERS� puNeis:Rec_Light_Sw._ ' ��'«-
connver�sanoN rr�sueAn�ce nno�ss l�'�4 Park View Dr #201
P„sr po
_-: (This-wctbn nwd aot iw cemplWad if flw work tmolred by Fotal No. Additional� � C� r@�'� 1
, 46e pam+it is for orw h�ndrad do(lara(�100)�m kss.} ' . ° � - -
!certify FFot in fhe perfarmance af-the work fw which fhis � � ' ������- -
permit is issued,4shpft not employany persorcinany manner � �-
- so.as to become subject ta the Workers'Compensation Caws: ��ghting Fixtures firsf 20 �� ADDRE55� .
� � � - - Total No. Additional -
_ . CITY Tel.No.
' Date applimnt --� Fixed ApQfiances Nat Over!HP pE�g - '
� NQtfCE TO APPLlCAMT:-if�,-'QFter�moking�this tertificate oi - � APP��{qry�n ��
Exemption, you shbuld become subjed to the Workers' Range_Heater_D.W.—
� Compenm�ioo provisions af the Labor Code,you-must forth- Qven �Dryer _W.M.— ADDRE55 _
with compfy with soch provisions or this permit sFwll be Top _FAU —W.H.—
deemed revoked.� - - . � CITY � Tef.No.
---. UCENSEO C(1FtTfL4CTQR5 DKLARATION - -- . H� --fan _Qther� � � -
� -LICENSE OR
. - . f hereby aRirm thvt f am licensed under pravisions af eFrop�er 4 Disp. _Room A'rr toru}. Y. ��.�UMBER d �t�� - .
r
�(commencirsg.with$ectiarc�700(3)�af�Qivisian 3 of the Bus'rness - 61STRICT NO. PROCESSED BY
. . and�Wofssaiona Gode,and my licerrse is in fulf(nrc8 and effect. Power Appomtus 8 Large Appiiancas � - �� a
- � - Size 8 Type NP,KW,�INA,or KVAR � 0
- License h�m6er. 4�a74$. . .Lic.Class.���� . � Up to 7 Inc4. . .. flNAI�� - . �
� CoMmctor Over f to-10 IncL �p`� � YAUUAFION Q
;�'��C�X'1('d� Dote 7-?�-��* 4ver 70 to 50 Irtc(.
FtNA ~
�- 1 am exempt under Sec.� � � Ovar SQ to 100 knc. BY � � . � � uu+
� � B.&P.C.for this reason � Over 100 � . 2
� Date: Services,Swbd.,MCC&Pane4boards � �
- � . - Q-206 Amp.Under h(76 V
_ Sigoature - 201-t000 Amp.Under 600 V � .
�167.[tA
❑ � , Over 1000 AmP-or Over 600 Y � � . .
�6cemption for Reg.Ma'rnt.Elect ��,� � ����2
. SlNGLE FAMILY Temp.Power Pole&Appwtenances �
- HOME QWNER-BUILDER�ECLARATtON Sigrt with One 0ronch Circuit- . -�• '��•F a
� t herebq affirm that I om exempt from the Coniractor's License Additionat Sign&anch Circuits ' �m �r ? r =
Law for the folfowing reasnn(Section 7031.5, Business and . . .�'U c:
� Prnfessinrss Gode):' . � �
❑ �,os owner of tha property,will do�he work and the Misc.Corsd�its&Condudors � � � Q 7�C�''�i J .
- shvcture is not iMended or offered for sale(Sedion � a��r(See Complete Pee Schedufe)� � �
� � 7044,Business and Professions Code}. ..
� CONSTRUCTI�N LEM1lDlNG QGENCY - . �
- 1 hereby affirm ihat there is a constructio�lending ogency fw
the performante of ihe work for which this permit is issued P€RMiT PEE - (Sub-Totalj - -- ----
- (Sec.3U97.Civ.C.J. .
. � � . � PLAN CHECKING FEE ��- � . - � .
- Cender`a Name � �
- . - PERMIT i55klMG FEE .
Lender`s Address . -
- 1 cer(ify that I have read this.apR��cation and.state fhat the_ TOTAL FEE -
� obove informotion is corred�I agree to comply wirh a�l County. - . . . .
. . ordinances and-State lows regulating Electriml wiring,and - . � .
hereby aufhorize.representotives of lhis Caunly fo anler upon � � � � �
, she ove-menGoned property for inspectioa�purposes. � � �
��„I�!//� 1�7EY~�� - SEE REVERSE FOR EXPIANAiORY LANGUAGE
, $ignafwe of PermiMee Date � �- -�-- -- �-- � �
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