Loading...
HomeMy WebLinkAbout1691A WORKERS`COMPENSATION DECLARATION� C�l0/ei AP�,t�CATIOhI �QR�ElECTRICAL PERMt? �. I bereby affirm rfwt 1 have a eertifimle of mnsent to self � � E insure,w o certificate of workers'Compensation Insuronte, COUNTY OF LOS ANGELES BUILDING Ai$D SAPETY ;. �w�a c r''ed opy t ereaf{Sec 38aQ;lab.C.)-.. ....__ - . . �: Pofi . t` Compony�flty - FOR APPLICAMi TO Flit IN JOB � Gert�fied copy�s hereby f�rntick+ed. EqCH �dp. F� A�DRE New Residential Bidgs. P I� � Certified capy is filed wifh the county 6uitding lrispec- - 1 6�2-Family,Sq.Ft. �u�� . f — & LOCALITY� ,.. �� �tio�deportmenL . -.-. ---�.- . � MuI1i-family Sq.Ff: - — NEARE57 � , - ti(•r1�/.-�q�.-� � . CROSS ST. L 8 �', � Date ` ��a�� l � Residential Swimmirtg Pools � . ..... . _._ L�_._ /�L�-4� , ._ _ . . . . . . .. OWN£ROR - - . - FtRM MAME . � CERFFFtCAtEdFEXEMPTION FRQM W(?J�!(fR$'�. � Outlets:Rec_Lighf_Sw._ ���� - � _- ._COfJ�PENSAftON 7NSURANCE _ : . . . . . . _.. noor�55--- ' -t (ihta extba naod nut fw eompkMd if 1LQ teeoek feral+ned by � . First 26 _ . tFv pormit is for one[tund[�ad dolbn(SIIYQ)oY lats;) - . Total No. Addilional � CIN - Tel.N � _ 1 I iertify.fhat.in fhe petfarmance o{{}�-wock fov..whieh tbis�- � - - � PIAN CH€CK . ` permit is issued,I shal[nat emptay ony person in any manner � APPL�CaNT :� so as to become subjecrto-The Workers`-Compensafion taws:.�. .. Ughting f'�xtures.- -. First 2C1 .-..--. _..�.... .-_.._. ...-..- . - AD6AES5--� . - � � � Totol No. Additiortul ; Date— --- ..- a�,rticqat . � _ . .. .. GITY TeL No. - NOFICE F4 APPLICAN7' tf;-n#ier making this fertifitate-b1�- Fezed Applr�ces Not Qver 1-HP. - � PERnn�i � Exemptian,_You shoutd-_6acome-aubjec�..re�'-ihe-'Wor�Cers'-._:_ ...&aoge_kiecsec._._.U.W.�.. . . . APPttG4l H ��. . . -_:_ ____..--------... Compensat�on prrneiswna o4-the taboc Code,yrxs_must futih- pven-._Dryer-._W.M.�_ - AD6RE5� . . - wikh campky wi�h`such provis�ons sx-#his permi€-.shnkt be-�. Fop -_fAU ���-_W.H�..-_ + ..�- ...-... _ - ��-... - -- . . . � .. .. .-. deemcdrevokedr.. .---... ..._ ..._ .. . .. . .. .. ... - . ,. .. _ �. � .�:-�-� I i[C£t�5f€�C6t.tararrrtwc�E}k,{�p,Fkg� ::_ --- K�ad -_Fou ..=0eher��._ �--- CITY __ ..• __ _. TeI.IJo.. . 4 - -- i�cerose oa - / — - ��ra 4i - Raom_AG Cond.-_ R �� „�� � I here6y aHirm�F axt 4cansed urdeE ptowisions atC ¢ �'_.— REG.NUMBER � (commerrang wirh Settiort 70pQ}af pivisrrn�3.vE the-:8useness . Fo,.�ecApFwrvtus Siorge Apptio.ices- � DISiRICT NCI. PRC�ESSE�BY , andProfass�nnsCode andm�.tieenseiai�fWtfarc�esn�ieffecr. P'° .. .. . � � . . . - -- �j-//'y Size 8_Fype tiP,KW KVk,or KVAR __.._ ._.:.-��._.... , : . __ ._�_ � license Num6ee�p�;�-1ic.Elass C�-'{�` -- Up to��l incl. .�. .. . FINAI _ �.. . � V . . Cantracror 7 .�Re-_�,,��,.�r�- Qver 1 to IO fnd. - � DA7E &->t .. a ��uL���-^ � _ ._ �t 4�t-_;.�- __ YRLMDhFK?N. _ QJer 16 ta SU-Frid. FINAL._ ' � F .. ❑� 6 om ex Pvrsder$er..- �- - � . - � � V __ _ . gnyp ____ -_..._. _- _Qv2r$a to T061nC. 85` W Over 700 � . . B.BP.C.for this reasan . 2� b%� R . � Services,Swbd.,MCC 8 Panelboards� � z ,� - Oafe: D-2a(}Amp.tJnder 660 V � �a�� s � • __.S�rmtore ' - .��Z(31-.100Q.Amp.Under 600 V � � Exemptiort frn Reg:Ma'mt:-$ect:-- � Over t006 Amp.o�Over 600 V - ��'•6&i 0 � SWGLE FAMILY �• •s fJ�.'� ^ i . � Tem Power Pole-&A � ��' � - HOME OWNER-61JttDER�DECLARATIOM P• RPurtenonces ! Sign with One Brnnch Circuit Q 7 L rJ.,.& .Jr i hereby offirm that 1 am ezempt from ihe Contractw's License . Law for the fulbwing reason{Secsion 7Q3}.5,�Bvsiness end -� AddiTinnal Sign-&nnch�ircuih - � - � Profess�ons Code): . _ .. . � ❑ .1,os owner af the property;-witt do-the work and the- �!�'Conduits R Conduciors _ � . � ; struciwe is not irttended or offered for saie(Section Qther(See Complete fee Schedule}_ . � �.. _-_ _- __._----�___.. . __ . 70d4.�usiness a�-Fro#essierrs..Eode},...._._. .. ....�. . __�_._ . _ __ . . _ . . . �_:... __ . ... _ .CANSIRUCTION IENDING AG€[JCY . ; Iherebyaff'wmtFwtxhe�eisesonskuctionlendirrgogency#or��- -� - � the performance of the work�for which this permit is issued pfRMiT FEE�- - - � (Sub-Totaf) (Sea 3097,Civ.C.j. PtkN EHECKtNG FEE � - . - tender's Nome � - � -� . - PERM7T ISSUlIdG FEE - � O � � lender's Address - � - � 1 rertity Ihot 1 bave read ihis applicotion and state that ihe TOTALFEE . //J . . hJ obove informotlon is corcecl.L.agree to comply.aei�-a€t.Go�nry.. . . .. .-. . _. . . - ordinances and.State taws regutafing-El�ckicat wiring,ortd-- _ .- ..._ ... -. . � . � bereby autborize�epresanta�ives of ihis Covnty to enler upon- � � the obove-menz�oried propeiry for i�spection pu�poses. SEE REYERSE FOR EXPfANATORY LANGUAGE ��, . �-�2�-.��-a��.r Signaruce ot P_ermi+tee . _' �- Date-. � - . . � . . .. .. �� . :...: ....._ . _. . . . . . . ._.. _ . . _ . __ � m� � � t�< < <s 0 , -o c ros�.a m �p � o . „.c ._ m 6 C i N � � . � . , . . m� w,p� n."� .M U a.o � ��' � d+ °'s ,n mo � o o"° � °.cd � � , �,.rr.n,u N :O N O Df C4 �N L L ; m t-� S E +' Y O � . �� L u 'O �.y � r�t� �; j W�O O- O m, O N,p N -6 p ,� s � O.� • pn 7^m °. � o c p c c u" o m v ° > o �� . . � . . . ' _ . G'O 01^ b y� C O 6� �p "0 w O C O a'81 .� G p _ . . Q o o �� o>.°. E � o°.Ns .��N ° E 3°s.�„ro � � ZO SN$ EN om�'� o+ TE o Tt� Nr���o.�n m � w ,�Y- -c m m m E o N o- c ro s'� '� r � Ec�� � yQ m� c Q; �ti-o °' as o o,=s N o ,Q, o o �..: _ m� .t o o�o .,cs � m'� � � ��;'*' ° Lt °£ � c E ° c n-cyow-oo� od .4 m . 4,,°`t, o �, m �r,o m p o o�-a r � n ^o s > c � p '., E rs m;;°s Y.��"� ro o,,,, ° µ, °' D o c.>�N"" a � s %�o � �-�'�-�c= Eo� o� N'o E ° m �; E o- o � ov „ � %� � o c ; »- E "- G �� a,' c° o �°,�° cNDnm c-n' 3 � �mmm o °'�-�o � o- i7 � � �, ` � o �`.' �� u o� rn c=,�a,�-: n� E m > w� � °� � os �: ^�,r-.o m n .U.� �'st c° c q m � �� 2� �w"OO.Dps 1'�� 01'� � �� o'V''-''= �CE;� C� i . �i \ � ;.o o :�o� c��`�'•� a � ,m/, o ;� .. �� O ` oa+ „ „ = ° o � y�,,oo y o�� Q� Evw "�o V� . �.` � J? � O � . ��� `- 1 t � ` � �` 4t J.- ` . .. �j ' � . . � V � C � C 7 � � A � �� �, • W � � N � � ,,, ,c � O Z i� � �o. o � o " a `� � �. V � a 4°'` j Z o � � � �',a � � � W x � �` � � � : . ,,��", ,--,''_�- ,.-`""�-.�