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HomeMy WebLinkAbout1660A (9) �WORKERS'COMPENSATiON OECIARATION � 76A663 �o�a, qpp��CATION FOR ELECTRICAL PERMtT � � .�� .I�here6y affirm that 1 have a certifimte of consent to seVf � CEA06G � � � �nsure,or a certificate ot Workers'Compensation Insurance, COUNTX OF LQS A�IGELES $UILDING AND SAFEl'Y w a tertified'copy thereof(Sec.3&l0,Lab.C.),-` . . . �. �Po�licyNq��;�ComQany_�, � � - -FORAVPUWNT16iULW- . � . � . 10B - -.. . . . �� , rtified copy is hereby fumished. � , .. , New Residentiol Bldgs. { �� nc0. e�E--�. Aooaes5 - � v CerNfied-copy is filed with the county building inspec- � ?&2-Fumily,Sq,F��.�— S — S IOCAUT kiondeportment. ...-' . . :. .� ... . . .. .Mu1Fi-fomrlySq.�Pt � . . . , -.- .- .'t+�AR€SF` _ - - - . .�._ :. _ .-- LROSS�SF. �- _ ... ..: .. � - �� �� ������, Residentiol Swimming Foots -- - Date �]-2�-$5,, A iwnY `f' . _- Owt�RpR � .-_ - . . . ._ _. _�, �� _. _. _._ ._�.:. ;_ FFRM WAlJE ��- _ . . . .::-CERFlF1G7EbEfXF1u1PT10N�RbA4�-LV�RK€RS'�- � . .- Ouflets:.&et,.y..,-Ligbt�..5w.�,,,, . . MAIt __ , . . . COMPENSAT16N1NSURANCE _�' ._. ... _ _ A�DRESS. ;_ (Thk;aetbnnaQd-notbocamPi�t�fft6av�arkinmlvadbr �. Farat-No. -� Addit�nbt � -- - -�- � � - � Fel.N . . :� Ih�pormH ia fur oxe hundred do}fan(51fM}or tass.} __ --- .` ..� -- ---- - - ;i ° - _ --- - vrAr��A�- �- _..� z ..� _ . .�. . �_ _„ � __ , 4 certify.that inT(he pecf�manca af ihe-wo�k far-which tbis � � - �� ����T �� � � � I� permit is issued,1 shati not emptoy any person in ony manner - - � . . so os to bechme w6jeci to-ikre�1A�orkary'-�ompensatiart taws. Lightiwg fiztures - Firsi 20 ADDRESS . Additionol I . � �Total Na � CITY Tet.No. 6ofe - - applicant � � fixed Appliances Not Qver 1 HP ��. NQTiCE TO APPLICAM1FT: if, oftermaking this Certifica�e of ���T Exempqan, yan should 6ecome-subject� ro fhe.�-Workers' ��1e-.-_keater_,,,_Q,W.__ . ���M F�TF� TiYY�:R F.F.FY'*PRT(' CompensertiOn�pttivisians�o#�-fFeta6br"Code;ybu"enusftwth--- �-Dven��_-Oryer _W.M.---_ A66RE55 - - `�- with comply-with�.fuch�gpavisisns-:w:.this-�pevmG�--sho!#be� _ iop� �_FAU� _W.H.— - .. deemed revoked..:,- �.,. _ . . _.... _ _LtTSC ._ . . --_ -_, . FfopC( .._Fun .-_OFiter__ __ ___ . .- � . . . tKENSEQCONTRACiQRS�DECtARATiON - - - -- �• Te�No-. ---. ,(herebyaffxmlku8iamlrcensed-vnder-£nuvrs�oa8oft;t�ppfer4 -.. Di� --_#toOnr7liv€artd..� _ .. . . . _ .` ' RE�6�N MB€R_ :..:. .. ...-CFasa ::: . _ �{commencirrg with Sectiort 7ClOQ)af Q�sicm$.at 7he Sustnau '�. - .- -. . :- �.- DISIRJEI�t6. � PROGES�D 9Y.. � anctProfeuioresCcx9e.or�mylicer�aisin.ft�!€�ca.flnds€fect. ._�._ Frnw�kppara�us&largsAppliar�cea .-.,... .__.. _. . -- --- .:_- ._ _ . _. ...--- -._ } i- .. . Size 8 Type HP,KW,KVA,or KVAR � � �' ...-� L�canse�Num6er - �?(1?dS2 t�,�,,.���_P�� � . .. � - --- �---- - . -_ . U¢to--kanEf- _ ___ -__. _____. FfNAI— _._- ---- --_ :.V.. . .-�-_ _:_: ___ �---- --- --- --- - - �.. - a��.�fa�a in�i. vn�i 4,_ � t_.�j vauo�uaµ p _. Contractor- T�'l;@�C.�'Sfw� Dote-��] ��"`$r3 _.� fher-IOtoSQ�Md. _.._ ._. � _._.. FlNAL•. — .�... � -� �-.i vrrGexempt.underSec.-. _- . .-_ .... --- -Over-30 ta 7067i5c __- --- - -- BY . . .� . . . . . . . _�y ' -� _ .-_ Over{00 .. :� 8.8V.C.fo.th�s reason _ - N �y� . ... .. -.. . _, . -. . . Services,-Swbd.,MC�&1'anelbaords ___ --------�---- -.� �-.. .. .... __._.. . . . . - _. �e� �Q-200 Amp.Under dqE)V ��� Siqnature :. ... .._ . 201--t660 Amp..Under 600 V � - c t b(ti Q� ❑ .. .-. , �rei�7000 AmP:-o��aver 606 V . _. : Esempt�aa for Reg:Malnf Etect.._____ � - - -,_ ._�- ----- --- ----- ---- - ------------- -------- ---------------�-•-F.•-r�_�--_. .� .... ..� .. .SINSi1�fAMt1Y , _.__. ;em�, g=p� .._. .- . . .-_. ._ ... .._. . _._ . �-- HOME pWNER B(lt1.DEK DfGERRRTlON -� --- ��y�a g�enth frrcuit - --- �� (-.� ���`�Q..--. �' I hereby affirm ingt 1 nm eaempt from il�e Contratt«�License ---- Additibna[Si n BranEh Circuets.:-:� �.�:' . . ,-�. "- .��- .-- - � � •e ..._4---� '�- taw.for fhe foltuwing reoson�(Section 7033_S,-9�sineu and .. 9 ..-.. ...'��5.5� " � .__ .__ -._. _ .._.._ _._ . Rofessions Code): _ _ (j'J�rJ�-�7 -_ ❑ 1,as owner of�he o�er �.- �.�.- -. Mrx�otidurts&Cnn3nct8rs .... . � - ._ - .. , . pr p ry,w�ll do the work and the . � - -shuctur�is r�9t inteadad.ar effered fer sa{e-{Sectean �._ 4dier jSeeComw�ete fee�Schednle� �-- - - T _ _�- -A_R. . . . . '�� -7044.8usinessandPro€essronsCodej. _ ,_ :.., , � . ..: .: �.,, — _ �.�. .. .. .... .._. - - � -._CQNSTRUCT70[i.LENDfNG:AGENCY __'_.__ `-`-- : . . - --- -. -. . . ....-- .. -_. _- . --- ::: _ �..r _— ._ -.-.::. z.� .-:..-. - IheiebyoffirmtF�it.lhereunconatructionleridingogeneyfw - . . . .--.. . --- --- -_._. . ��; the performanca af the work for which th'rs permit es issued . -�. pEkM1T fEE '-�'�--�-��� �- - - _-(Subd�tal}' � �-� .�., -_.. �� � ` (Sec.3047,�Ccv.C.). : , _ . :. _ .. . --� ,__:. .. .. _. _. .. . _ - _ ._ . . .... --- - - - �:- _:.- _ � ��•� --� - .__ .�---- --�-�- � YLAh3CHECKtNGfEE:.:: :.�.:_. ._.._.-_ -:_ . __ � ' _ . _ . . ' Lender's Name � . .. . . .. ,, . .... _ � ._. .� . . ._- __.. ' - -- � .. .. . . PERMtt-ISSkiiNG F€E--_. . .. :�.. - � �: . � Leoder's Address_ � � ._.-. ; . . �... . ._ .::.�.. . ':_. :._ _.. --: ._ . I cerrify rha�I hpve read this applicafioo ondstate thot�he --- T����� ��- � -. � . --- .._..__..__�._�_... above-informatinn is corrett.1 agrea ta compty with ott Couary �. . �.�-- -:: .:..:. --.. ...- - --.�- adinancas and-Stote laws regulbtiog Elechical wiring.,and ' � - _.__ ._ . . .. .. . . .:---� . . --�-- - ....-- -. _ . :�_�... ..... . ... . . . . . . _ . . hereby oeithorize represeniWivas of this County to enter upon� . - .:.....- ----.. .._._ ,._ .. �._.: .._... ..--._ .:._ ._ the a6ovB-menrivned_property for inspection purposea ' � - � " � � � -._.. .:_ __. _. ._ . ���p�� ���� � � � SEE&EVEdSE FD&EXPLANATOBY LANGUAGE - �ignotura of Permittee - I Date � . �--� -- .. � � - - � � .. . - . .. . . . �- . . � ' �" �n �-� m O� +. 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