HomeMy WebLinkAbout1681A (10) . WpRKERS'COMPENSATION DECIARATION 76A563 t0/e� �pp��CATION FQR ElECTRtCAL PE�NtiT �
1 hereby affirm that-t have a certifimte.of consent to salf �-8�'
insure,or a cert�ficate of Wwkers'Compensation Insu�ance, COUMTY�F LQS ANGELES $WLDING AND SAFETY
. dr a certifi co� thereof(Sec 380Q Lab.C. . .
� PolicyN . ny �FORAPPLICAM70RlliN—�._.._ _ _ __. J68—___ ______ ._.. ... . . . . .
�Cerhfied copy�s hereby furmsAed. - — � - New Residential Bldgs.&Pools EA�H NO'
ADOR
i a 2-Fam�r Fr_ 1775 a , 4 — s 1 00�ocAUTv
i.Eertified cogy is filed with the-county buifding irrspec- Y.�Q�
. �-tiort dep4rtment. . � � MuNi-family Sq.Ft � - — N��� *"j .
��� T m�F� Residentiaf Swimming Povls �R� �
Date Applicowt . - .
FIRM NAME
- CERTkFICATE OF ExEMPTION FROM WORKERS' Out(ets:Rec_LigM_Sw._ - -��E
-
- fOMPENSATION INSURANCE � � - ADpiESS '
� (Tbis.soctio�nqad�rot bq complQtQd tf/Mw work Mrolwd yy firs�20. .
- Tha p�rn�#k Fs far o�hundrad daflers(S#69)or kss.}•- TataE No. �Addrtional Ct�` __- Tel.No. � — 41
_ 1 certify that in the performance of the work for which this � ��� � � -
, perm"rt is issueti;4shatl nat emptoy any person in any manner � a���� -
so as to become subject to the Workers'Compensation Laws. Lighfing Fixturee First�20 � AODRESS
� .. . Fofol No. Additional . -. .
Oote � erplicanf -. CITY- Tel.No.
- � -N6T�CE TO APPLICANT:if, afler making this Certificole of F`zed Appliances Not Over t NP . pE�F —'•-- .
Exemption, -yoo should become wbjeet �o�the Wwkers' Rarge—Heater_D.W._ A��M n �p
. � Compensation prov�sions of the Eabor Code,yon-musi forth- Oven _pryer _W.M.— - AODRESS � �a. Z],11
. +xifh mmply with svch provisions w this permit shali be Top -_FAU �W.H.— � �
deemecF revoked. - - � _ � " CITY � • TeL Na.
. �_. -- LfCENSED EDNTRACTORS QECLARATlON Hood _Fan _pther_ Q'1�.I1(} �J91�64�1
� Disp. _Roam Air Cond — ���� Class.
4 herefiy affirm that 1 amlicenu.d under pravisions a#Ghapter 4 . - REG.NUMBER�ZQ74$ �
(commenting wifh Sectian�7WQ)-of�;Ykswn3 af ihe Business power Apporatus&Earge Appliartces DtSTRICT NO. � PROEESSED BY - �
w�d Professions Code,and my licenre es in fulVforce ond effect - Q 0.
Size 8 Type HP,KW,KVA,or KVAR- 0
- License Number�tic�Class� . .
l�/y�/ '� �J�j..� Up to}Ind. PINAL �
—. ContradQr����r! rf/�pate� ��� . �er t�0 16 fncl. .. . DATE�`—�,Z�w� YpIIDATtOlf �.
� . . . Over IO to 50 Ind. RNAL ' . O
t am exempt under Sec. pyer 50 to I00 Inc BY uui
. . B.&P.0#or this re¢son Over i06 . � s' -
N
- � Services,Swbd.,MCC&Panel6oards Z
- . . . �Qofe: . 0-200 Amp.Under 600 V . � � - e� t1 FS� h -
- S�gnarure ZOi-1000 Amp.Under 600 Y � �
. ❑ - Over t00Q Amp.or Over 60D V ���i • • •2.
Exemp�ion for Reg.Maint.EiecL �
I •�&1,5Q
- SINGLE PAMILY Temp.Power Pole&Appurtenances
- ` HOME QWNER-BUILDER DECtARATtON - � Sign with One 8ranch Circuit ••���:�,,�i U c=i
i hereby affirm that i am exempt from 1he Contrucror's ticense . qdditianol Sign&onck Circuirs -
, Law for ihe following reason($etlion 703L5, Business ond � �7 2���5 j
Professions Cade}: . .
❑ i,as owner of the ro ert � � Misc Condoits&Conducsors � . - -�
p p y,will do the work and the p�her �ee Com I
structure is not intended or oHered for sale(Section �� � -p ats Fse_Sch�duleJ_ �
7044,Business ond Professions Code).
CONSTRUCTtON LENDING AGENCY � ..
� I hereby affirm that there is a construction Iending agency for -
the performance of ihe work for whith lhis permit is issued PERM4T fEE-_- - �-� -�- � (Sub-Totol)
. (Sec.-3097,Civ.C,). - - - .
- PLAN.CHECKWG FEE- . .
� lender`s Name . �
� � PERMIT ISSUING FEE - - �
Lender's Addre:s �
1 certify that I have read this applimYion and state that the TO7AL fEE . . -
. above information is mrrect I agree to comp�y with al�County . - - � - � � � �
ordinances and State lavrs regalating Eletlrical wirinq, and _. . - � -
hereby authorize representatives of this Counry to en�er upon - - �
the 6ove-mentianed�praperty€or inspedian purposes. � � �
����t__n, ��} SEE REVERSE EOR EXPkANATQRY:IANGUAGE .
r� �G1_��/`C=
Signature of Permiitee � Oote - ]
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