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HomeMy WebLinkAbout1691A (10) 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-. � - . . � . . .. .. �� . :...: ....._ . _. . . . . . . ._.. _ . . _ . __ � ' ;,.- ' ",,;,�y b m,,�'�Y, •� o=m � a t�i, o `o c�° ' oo,"�,a N °"- 3 o.a° m a� ° � a" m c�m n �mbocca�'� °'.e `o U° �d `a`ooa , ; ; U o o y.,.` �N m oc ° � i m m��_° �'�u,�-• • . � 0 �'s N O � J � � E „ �E � � �C � y m� � ��w. 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