HomeMy WebLinkAbout1682A � - WpRKERS CDMPENSATION DECtARAT10N 76� ���et APPLICATION FOR ElECTRICAL PERMIT �
� 1 hereby offirm that I have a certitimte of consenl to self �"�
iosure,ar a certificate of Workers'Compensation Insurance, COUNTY OF lOS ANGELES BUILDING AND SAFETY
� or b certifi d cop tt�hereof(Sec.384�0,lab./C�} �
•. P�ol�icy N��ompany,�Jy�/7 -. .:. . .FOR/�ILI[ANT TO HL!M..... _.- �- -
___ ...
' Cerref�sd c �s here6 iurnished. EACH NO. FEE � a�� �
r �. oRY� Y New Residential BCdgs.&P Is -
� �.�( l 8 2-FamJ �5 �-Ft:y� E-/ — S kOCALI - -- -- -�-
�� Certified copy is fited.with the munty building inspec- Y• 9� _ �NEARpST �
� - Yion department' �N��f_�rr�:`G�-f/ Multi-fomdy Sq.ft. CROSSST,
Residential Swimming Pools pWNER OR
� Dote 7:��Appiicont� . . . FIRMNAME -
� CERTIFiCATf OF E?(EMPTIQN FROM WORKERS' - �+��-- - - -
COMPEN5.4TfON tNSURANCE Ootlefs:Ree_Light_Sw.,�,_ pooRE55
first 20
(Thia sacfton�wad nut�complofad MF th�wark Fnyofved bY CtTY. • Tet.N
tl�e p�rm7t is#oe ww F�undr�d dollers f ft8@j er lasf_}- Tatai Na Addirfanai i
� _. ... __ .__. - . . PLANCHEIX �- . .
4 certify that in ihe�3erformvnce of tFie-workfor wFiich sfiis ppplKqt�IT
perm8 is issued,t shafk-noi empfoy a�y person in any maoner
so as to become sub[etf to the-Workers'Compensation tawa U9hting FixNres First 20 ADDRESS
Additionol
Total No. CIT1f Tal.No.
( Date AppCicani - Fixed Applionces No�Over 1 HP PERMIT � - � � �
NOTICE TQ:APPLtCANF:�lE,aNer making th�s Certificate of aPPtiCANi N H �
�� Ezemp�ion, you�shauld 6ecort�e su6�ect ta the�Wwkeri Ra�ge�Heater_D.W._ � -
Cempensation prorrsiwn of��he Fflbor Gode,you e�ustitrMh-- Qven �Dryer _W.M.� ADORESS�� � 71 7
with comply with-such-provtsrans cr-#his permiP�shatl�be Top _fAU —W.H.—
t deemed revoked. � -- -. ___. . .. . GTY� . Te{.N
s . ._ . _._..CICENSE@ CONTRRCTdRS DECIARAT(ON._.._. Haod _.Fan _Qther_ (P�NSE OR. _
j- F heroby qffirm i#wt t om_licenset#under pmr�si�cLCk�ttpter 4 �'SP• --Raom Air Cond. _� RE6.NUMBER � - -
(commenci�g with Secpon 70Wf o#Divisiort 3 of-ffm�Business� - - � DtSTRICT NQ. PROCESSED BY �
Pawar Apparatus&La.ge Appliances - �
i
and Professions Gode,-and my Iicense is in#ulf farte and effect. - �y, -- p,
, Siza 8 Type HP,KW,KVA,or KVAR V O
�,,//� V
� ficense N�mber�fic:Eiass� Up to 1 Inck � PtNAL �
F/,�('1�Q/Lf� oare � � �.,�
7 f?vec.ila]41nc1. i�,.4-� ��-'�� VAl1Dl1TIQN Q
. - Conlractor�,._ DQie_.�C� Over IQ to SQ Ind. FINAL � G~J
q � !am erempt urtder Sec- -�--- �- ---� ..-. _ Qver 50 to 100 inc ffX �. - - �
Qver t0U �
` &.BP.C.for this reoson � z
t � Services,Swbd.,MCC&Panelboards � � �
Dota: . p-?pQ Amp.Under 600 V �
i . Signature 261.-t000 Afnp.�Under 600 V� � �
❑ �- � . C}ver 1000 Amp,or Over 660 V c� 6�.-�R
.€xemptian fov Reg.MainL Elecf.
. . �j��v • s �'�
� S�NGLE FAMILY � - Femp.Power Role-&Appartena�ces - -
` HOME OWNER-BUILDEk DECtARATIpN � •♦
., Sign with One 8ronch Circoit 1 71.7 p
- 1 hereby affirm fhoi I am exempt from fhe Commctor's License qdditiona!Sign&o�ch Circuits � . . - -� � ` x - �
� Caw for ihe tollowing reason (Section 703i.5, Business and- � (T,7(�j c;
P•ofessions Codej:
�� ❑ I,qs o4+rner a€the property,will do fhe work flnd ihe M:x.Conduits 8 Conductors �� �����.�8�
F sir�dure is nor intended or offered for saie (Section �ther(See Complefe Fee Schedule}_ � _ .
7Q44,Business and Professions Code}. - . �
CONS7RUCTIONLENDWGAGENCY � --- ----�-�-�-- - .
I hereby o#iren that tbere is a consiruction iending ageocy for
�the pehormcrnce of the�work for which tbis permit is issoed pERM�T FE€ �- (Sub-Totat) � , -
(Sec.3097,Civ.C). � . . . .
� . . PIAN CHECKING FEE � - -
� Lertdei s Name- . . . . � .
PERMIT i55UWG FEE
� Lender's Address
I certify fhot i hove read�his appiication and siate thot ihe � TOTAL FEE�
a6oye,informption is correct.I ag�ee to comply with aIl CAunty
� � ordinances and Stote Iaws regalating Elecrriwl wiring,ond . _ . . � _ .
hereby authwize represeNatives of this County to enter upon
the obove-mentioned property for inspectto�purposes. SEE REYERS@ fOR EXPLANATORY LANGUAGE
�� �?��c 7��-s'S �
; $ignature of Permittee Date - �
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