HomeMy WebLinkAbout1659A � WORKERS'COMPENSATION DECLARAFION 7aa663 t0iet APPLtCAT10�H FOR ELECTRI�AL PEt�llfllT �
I hereby aHisen-that I.have a.certi4icate of.consent to seff �-� . .. __._. �_. . ��. ...-_ _.... _.._ .. -. - _- .._--_ -. �
: insore,or o certificate of Workers'Compensation lnsurance, COUdTY OF LOS ANGELES 6UILDING AMD SAFfTY
orncertifieztcoQy�ther�af-_{�c._3840,_lah:.C_j_ ... .. . � , . . . . .
Rolity • .. . CQmpany�� - .. - POR APPLICANT TO flll IN � � �.:-.. � ..�_ ._ q�ODRE55�],�j._ _ • (i, . ,
� � etlified ca is here6 fumished. �� � �� �
•.Lt .. . PY ....Y__ ._ - __-.- - New Residential Bldgs� I� �
- +�ertifiad topy is filed wiih Ehe county buildir�g ir�spee- 1 8 2-Fomi1Y,Sq.Fj�i s — $ LOCA!
tion deportment.. _ ...- . ..-. � Multi-tamily Sq.FY. — �bEAREST �.
�:� .. - � CROSS ST. �
?- 5 . ��T�. (t'['�.F[,kY'�I�RT' Residential Swimming Pools OWNER OR .
Dofe 7�.._$ Applicant C . FIRM NAME � . .
- �--CERTtF{fAIE OF EXEMPAaIJ-EROM WL7RKER5' --- Outlets:Rec�Light_Sw:, '����
� - --�- COMPEN5,4FION tNSURANCE � - AooRE55
First 20 •
(Tlds wetbq naad not fw complotad iFtho�vrodc involved by Totoi No. ,qddifiorwl - GITY �� � Tel.No. � - 1
tht parmit i�fo�uno hundrwl doliars(R1W)or lass.)���� ',
I certify that in tbe performante-a#tNe work-'tor-which this . . PV+N�HECK
� perrtut is iuved;f shatt tibt emptoyany persbn�n tiny manner - � - - � � �l�A�T .
sa as ta become subject fo the Workers'Compansatlon Laws_. tigMing FixNres First ZQ ADDRESS
� � Total No. Additional - � -
CITY Tel.No.
Dare � � applicant ---� Fixed_Appliances Not.-Over t NP._ "
_.. ..PERMIF--.. ._.._- --
� - NbTIG€�7Q APPIICANT�.'7f��a{fer makte�.-this Cerfif;cgte o(�_... ---�- -- -- .... ... . .- _ .. ._ . ...
Exemption, Yav shoold become�subject te the YYorkers` Range�—Heater�_D.W. .-_ -... . APPCICAhtt+� tr- .��I _.. .
Compeniation provisions af-ifse#obarCode;-ya�i-mnatfarth- Oveq_Dryer _W.M.— - ADDRE55
with�campty with�s�ch-provisFons ar�thfs permit shrati be �Top _FAU —W.H.—
deamed revoked.-�- .. . .. . Haod _Fan _Other_ E� � - Tel.No.r� 1_ 4
�- LtCENSED fONTRACTORS D€CLARATION � � UCENSE Ot�
- I here6y affirm tkwt t am licensac!�srxle€pravlsic�ns c£-Cfz�pte�4 6isp. _Room Air Cand. — R�G.NUM@ER C(oss. �
(comm�nc�ng w"rth Section 7pp6)�of pivision 3 0£the Buainess power Apporatus&Earge Appliances � 6ISTRICF h}O. PR�ESSE6 BY �,
� a�d Proftssians C�e;and my license isi�.#�Ik4rnce m`d�.effect:�. x
-. . -- . - -� Size 8 Type HP.KW,KVA,or KVAR� .. C�,t Q �
ticense Num6er d2R7dR Lic Closs C-1�i � � Up to 1 Ind. FfNAL . . .. v
F.lcx�f•_ric�al f>ver 1 to 1D Irid. DA� (-��r,•-';_-`,-'� VAIiDAT10N �
- � Coniractc+r � Qate� 7-22-$5 Qvar 10 to 50 tncl. - ���� � �
� � i om ezempt under Sec.-- - 6ver 50 b 100 Inc. - - BY w
� B.&P.C.for this reason Over i00 �� �
H
� � Qate: ����ces,Sw6d.,MCC&Panelboards - � - z
- - - 0--Z00 Amp.ltnder 600 V � . �}�J�g A �
. Signature 2Ctl-1000 Amp.Under 600 Y _
' . . _ Ovar 7406 Amp.w Over 6�6 Y . �� �.� • �2.
� Exemp�ion for Reg:MoinL Elect.-� _ . �-� }�y�j,5�
� SINGIE FAMIiY Temp..Dower Pole B.Appunenances
HOME OWNER-BUILDER DECLARATION $ign wHh One&a�ch Circuit •��� C u�C�
I hereby offirm that I om exempf from the Contracror's ticense �pdditbnat Sign&bnch Cirtuiks - �
- . law.for the fQltowing reason{Section 7031.5,8usiness and - - , �^�2���rJ
. Professions Code}: � , � �
v
� - �- - Misc.Conduits&Conductors - � - -
1,as owner of ihe properry,will do the work and the Q�her See Com lete Fee.$chedule_
� � sttuctwe�is not.infended or o4fered fw saie(Sec4ion � P ) �
7044,Business ond Professions Code). _ .
CONSTRUQION IENDING AGENCY - _
I hereby nffirne thaf there is a mnstrudiert lending agency for � . .
the perfwmance at ihe wo.k for which this pe.mir is issued PERMIT FEE � � � (Sub-Totol)
- (Sec 3(}4J,Civ.C.). �
' - � - - PtAN CHfCKING fEE . - -
, Lender's Name � �
� PERM7T ISSUING FEE �
Lender's Address ��^
.� I certify that i hove reod this applico�ion and stare that rhe TOTAf fEE . (� - �
a6ove information is mrcetl.!c�gree to compiy with oll County -�
� ordinances and Srote laws�egulating Electrimi wiring,and � . �
, hereby aathorize representatives of tfiis�County ib enter opon _ . . �
the a?6ove�mentioned property for.inspection purpoaes. _ -
�LG�C.�I�i LY• !/rJ��� SEE REYERSE FOR EXPLANATORY LANGUAGE
- Signature of Parmittea Date . . . €
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