HomeMy WebLinkAbout1674A (10) 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 � �- -�-- -- �-- � �
-------. � _ .
a"?a H@ �-�mt�� � o�-rym c i, '�a °e ° .s.�.v
O�'t A ,�+ '3 o a.° o g u." m e
3. N y � �O�Q b �1 C Y G Q y y C 1" . ' ' , .
� �a a� c�ai" m.c o` ti n.�' °b o 0
U o �a'm a''� m o c:° � i � ai�o�° c�m.e
� . m�no .. � „ � � � EO °u'z � �~ �{ E '�'�' Ec=
O` � o,M„�a�, mo,e� u�� v°°vo.bom� o„`"�. ,
a � o '�' E , oF � m o � _� o � � .. � o ao
Q; oy.�� p�'m `m ' � m 3m« a °E3 �° N :
-* aa�:� m o€� ` �-° a.� o m c o o m c o
Q yar�° � m � o..�a^Qa� �°NQ��„�-' �> > " ..
c
p °' ov°` f'�2� �.o'+ ko `o+�. n�000�pai�m= :
.r �= N � ' n 3 ��.a 4.. � o'O G' � nm r=,. u�i� "S- L m � - ,.. . .
. �' �y�" O 0 � � ..�i� � ��' � m C a m O N u�i � ' .
>'O �
m rt m N o �'�� e _>.e.K �°+o o c � m °�°� �m '- �
w �+.«�' .. �� �u cn a m a.m `n. Nb �>ro'o� Q � N
Z � �� H� u p w'g o a., 3 °c c p£ a�1 3 �y � �
Q, � �
''b m i�qp o��p�.4 m c�,o°v ,�j"i °�o m£ pa ..
�� 0 3 C a��0 O,C�;q.O,.. O u y d �,� y Y'! N p �'� p � O . . � . ' ..
.. �. TJ,N �y�.i.� O�.^b O�O�q_,.�, m b �� � �.D N , . �
y ;n �,p•._,t'�i,c (3 � . p `�` j= m -O�. x U ► . . .
� m ` �o.M o',a u��,. C❑ r•.,-c �o o �� m d
.°c u � $'x� � o'a o 00 0 o sva, `o'sY c E� o o. °� 0 3
__,.m � o c�Euw ��..n ut .�.. 3 � . o c _ m � O
� � �
W
OC
z l
�
v�
w
c
� P
a C �
� �
0
�
:
�o '
.._
� `�` a k ; � F
• ; � O n O 0
� s s � C9 ¢ O
Q � �
Q J �
a w C7 2 � �+ � '
,Y s .� a �"
. � �' � 3 � S5 � ° '