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HomeMy WebLinkAbout1041A (5) WORKERS'COMPENSATION DECLARATION 7fiA683 70/87 AppLICATt�N FOR ELECTRICAL PERMIT � � 1 here6y affirm that I have a certificate of consent to self inaure. �-8� � � or a certificake of wQrkers Compensation Insurar�ce,or a certified COUNTY OF LOS APIGELES BUILDING ANQ SAFETY � copy thereof(Sec.3860,Lab.C.) _. _ Pdicy No..� Gompeny. � � Fat avrucnNr ro Flu.iw ,roe ❑' Gertlf�cf coPY�S herebY furnished. . - �EACH NO. FEE no�aESS- ..�.. .._. ._. . . _ . .. . _. _ .. . , . . . New Restlerttiel 61dgs.8 Wds . _ "'�� Cert'rfied copY���ed�with the caunty 6ui�ditg inspecibn t R 2-farnity.Sq-Ft $ — $ LOCNJTX .. - �depaztment... . . . - . . � MWti-tamily Sq.Pt. — N€ARESI . ,.. . . .`�.� CR0.S5 ST. Date . . .. .. . App�icant ..... � � Residential Swimming Poo�s � , � OWrvER ' . . � . .. . .:., _, . • FIRM NAM -GEE€TIFICAT���F EXEA@PTiONFFt3M=YlY3RK€R�',_-... ��- Oullets:Rec�� Li9ht�Sw.�.. ' .- �-.- :. .. G6MPEN:,ATKIN INSl1AANC€ .. . ... - n��tESS ' (Thlf sectiQn_�eed nct ae--ss�mpleled'H�.iha+erork FmWved-bY ihe q� FiBt 20 f)@flilit IB fW 0118�111fit�FBd�I�dlS(�100)a�686.} Total No.!f Additbnaf � C�TY T���� !eBftity_fhaY in the performance af the wock�for whicFt Shis permit . . � PLAN HECK-- �� � is issued,I shal4 not empby any per�on-ia aay-ma�r ep as to - - ��1ep� . . become subjectto Fhe Wwfcers'Com� ws. Lighting fixtu2s First 20 � A6QRESS Tota�No.� Additional Date Ap'., - aTX-� Tai.No. .N4UG€- TQ-,APPLEGA�kT=. Fixed Appliarices Noi Over 1 NP . -tf, . a4_thes GeF.. of. PERANT� . � EXenVkan,Yai.slwuklbeeome . �. ttathe:YYockefs'GOmpeiitsation .-- —___Rar�— Heater_„_,,,_,_D.W..._.... . . �'��T � . pravisions of Yhe Labnr Code.You mus[brthwith comqy wiN such- Oren_ Oryer� W.M._ - . ADE3RESS.'.. .. ..- -- .,.' -. .. -. .-...__ . .Provisions or this permit shalt be desmed ravoked. � ToP —FAU. _ Y�.li.�.. ._.__ . . " .. . ..UCENSED.COMTRACTDHS DECiARAT�N �. liood�Fan _ Ott�x_ .. . . �. . .�Y TeI.No. � . . .. �t hereby.affinn that t am I�ensed under provisionS.ot Chapter 9 . . .,._.�.._�.��: _ LJCENSE OR � � � (CamrtlellCiRg with SeCtion?OQO}of 6iv�Sb11 3 QI.IFI��1191f1eS3 8fid - . . . REG.NUMBER-�_.- .. . . - _ .._....C��%. . . - Protessions Code,and my�license-is irt full.force and effect. �.���t�$l . . . qs-rRK;T NO. . �O .. . pppC�� ... �_ . . . ._ arge Apvliances . _-. . ..., . Size&Type HP:KW,KYA;or KVAR� � _ a� ` Licease M1lttm6er Lic:Ciass --- -t!p to t Incl. - � FtNl� / C7 � Over t tn iQ�nct. DATE /� Conaactar Date � � . ._�f I�� V�uDAT10N - . . O � — � ._ —.. _ _ _. __.. . . _ . _ . ._ O�r ffFtc5f3�Mct.. _ ... ._ __. ._ - � . .. FINRL .. . � ❑ I flm e�cempt untler SeC � , f}ver 5Q to 100 Inc. BY. - _ W Over 700 - : B.&P.G.for this reason � � - �Services.Swbd.,-MCC&Panelboartls � . �� - � z Date: . 0-200 Amp.Under 600 V � . � � Signature .. ... . . ... ... . ..._ _.201-t006-Arc�-Under-600 Y � � � . . . _. . . .. .. . . ... ... .. . i . O _.. ._. . . . .. .. .... .. .- Ovar 1000 AmP.w Qaer 600 V . _ ...._ .. . _ . _ _ .. . _ _.._ . . ExemPtion for Re9.l�irvt.Elect� � .-_.. ._. - _,-. � . . ... .. . ...--S1�7GLE FAMfLY:. - . _ _ . ... Temp.Wwer.P�le 8.Appurtenances . . NOME OWNER-BUIIDER DECLARATION ggrz witry p�y&anch CircuN - � ��- - � - I here6y ffirrn thet I am e�mpt irom the Contractor's Lr:ense Law � � tor the lowtnc�reasan(Section 7031.5.Business and Profeseions � Addit'anal Sign&zmch Gn:urts .. _ . ... . ..._.. : .. . CoUeY `/�,� • i.as owner of The property,will do the wwk and the structure� Mise.Cor�fts&��Canductors .� .- .-.. .:..� v 1 ��) A � is not intended or offered far sale(Sectlon 7044.Business m�«E°��ete Fee Schedule)._ G and Professiorx�Code}. . _ - � � {�• • •��.•� . GONSTRUGTION LENDING AC�ENCY - - - -- - � -"� I • •���7.S J I hereby affirm.tk�t thera is a eonsVuction len0ing agency lor the � perfamance of the work tor which this permit is issued($ec.3097, - -pERMIT FEE (Sub-TotaV) - - - � � � �2��'�* GN.-C.�� . . � . � . PLAN GHECKtNCa FEE" . . .. . . . - Q��Jr�FS 7 Lender's Name— � - - � . .- .f'ERMIT_fSSUUJG.FEE:..-..._ .. _ . . Lenckr's Address -... . - � ' � -- i certily that 1 hsve read�tttia aPW��ar�state that the above � TOTAL FEE � �} F•, infarmation-is Cortect 4 agrs6 lo.corriply vrith aI{County ordinanGeB - -. ...-. .. and State laws regulating Electricat wiring,ard hereby autfmrize . - representative his County to upon the above-mentio�ed � . . . .. . - . .... . . txopa a ctun pu��, � -�-- � SEE REYERSE FO&HXPLANATORY LANGUAGE � u i tee —. __�Z� � - � ` �_ ; m+'� E _ � v, � v, a� �. m ; y � '"'o .� � eCn 3 . � � � ��- w � - � f.N'�:4'i Q-'O N � itl . :,(�� a �,'N �tl . . . ..,,.. � M . . ' . � .. � � � O' � S �U5�, +'O -0�,. � �,�y '�� .-� � � ���. � � 6 . � '� �_� N � " � y �i � y `n "� '� � � �''� � �y � "g 1,.d � .o � .� � Q� E ,�"a � �, �-.., O W � � �rn �i m� � � � Mn o � � �� � � �� C<5 � ��5c 4`. � Q Up { �� a� : � � �7p � ai � p3 ��-p?� �� . . . . ;. 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