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HomeMy WebLinkAbout1692A ___ _ . _ _ _ --- - _ -- _ _ _ _ _ WORKERS'COMPENSATION DECLARA710N ��`� ���81 qP�LIC�T�01�-�OR--ElE�C7RICAt�� PERMIT 1 hereby aff�rm�that 1 have Q cer�ificale of c9nsent.to se{f �E'�G -- - - � �nsure,w a certifiwte of Workers'Compensafion Insurance, COUNTY OF LOS ANGELES 6UILDlNG AND SAFETY ot a certified c]opy yt reo�fj�ec.38Q�0,La�b:yC�.} � � . _P�ol�icy.N6.�" r��Compnny!LT ..... .. ._. _ ...F04APMICANTi4FfLL.IH ._ _ !49 .. . ._.- ___._._ __.-- -.-- . Certified copy is heeeby furnished.�:-_ . New Residentiot 81dgs.8 0 �� Ns?-� -- � � ADDRESS. � � ' t 8 2-Fqmil q. LQCALI7Y -• ' -� aCertified copy is Piled-with the caunty b�ilding_�inspeo- Y�5 --�t-�� s.... � S � �$5g ... ... :... _ . _.. —._ _ NEARESi..- - tion depprtment � r r--' -� Mvlri-family Sq.R.� ��557. (O-f '.t �- _ �C�'� !�,� Residential Swimming Pooks �ate.�,�_a-�ApgHcant � .��S7�E ... _ . ... ... .. ._ ..._ � QwNER�OR . .. . . . . . -. _. . _ _ _-_-f�RA4�FJRME � ` CERTifK'A�f QF�EXEMPi10N'fRC)hTi��MORKfRS`�-� . . .� . -:. . - _. ,wtit .. -._,._ _... _ .. _ ._... . .._ ... . . Oudets:.Rec_light—$w'------ _------ -._ _.. RDottESS�- , �__ . . •. .. . �-�Ct�MPENSA7lL3R1lNSE1RATdL��-_ _ - . .. . First 2Q� . ���(Thls-wetlo+enaad,atfw-cna�plQlodifNwworkiwvolvaFby�-� � Total No. Additional C3TX Tek.No 1 the permlt-4s for on�hund_red dallars(�106}or laas.}� . . ' .. - . - �i certify.thaf in.ihe perfoimante aE fMe werk#or which-this� � . � p,��ryF � � pe�mi!is issoed,i ShaII h4t empiay ony..persan,n any mvnner. .- . - � ._ .._ __ _ _. so 6s to becoreee suhjett To Ihe Workers'Compen"soYion Caws.� Lighting Pixtures - First 213- -"" --"��"�� "�-- " " RD6RES5 �-� � Total Na � Addirio�al - � . ClTY Tel.No. .Date °FPIiGgnt � _. - .-.-____ Fixed Applionces Not Over!HP �- PERMtT . N6TICE TO APPUCANT: If, after moking tfiis CertiFiwte of � �r n - �.Exempfion, �You shoo4d-bccome-svbjec4-to-tFe--Workers' .-.-..�QBe._..Henker_4.W.�... APPlICANT `.[` Compensatian provisivrrsvf-t#ietabor£ode;•yov�most-forth- - Qren��_Dryer _W.M._ �. AODRE55 �.Q. � �l�l wieh comp4y--with�svch provis'rons-or�this paimif shaFl--be- - Top. ._fRU —W.H.— _ - �deemed�revoked. - . .�. - . CITY Tel.No. � LtCEP[SED CONTRACFORS DECLARAF{ON �.. Hood _Fart _Qther_ � - - � � - Disp. �Room Air Cond. — ���� � Class. - - �{hereby a�irm tiwti 6m liCe�isedu�ufer pcouisioqcof-C.F�apter 4 (FEG.NUMBER - (commencir�g-wifb Secticu3_7004}of Division 3 of 1he Businass_ . DtSTRICT NQ. PROCESSED BY� � ` �and Professioos.Code.cind rtry}iceme is-in fvfl fiorce or�d�effecY�. �- fowar Apporotus�&€arge-Appfiorrces� `/ Q , . .: � �f���tS . . ^-f� .. . Size&Type HP.KW.KVA,or KVAR- . .. L� -4 License Number'7 7 � Uc.Elass t- ! Up to 1 IncL FINAL � � V �Q/ Over 1 to lE}Ind. 6ATE t� �—�my YRLIDATfON Q Cantranor�"'"""'� Da�e__�� � 6ver IOto561nd. � � FINAL � ❑ 1 am exempt under Sec. - Over 56 to 100 Inc BY - . . �W . B.BP.C.far this�eason -� Over 100 . � . . Z - � � Date: Services,Swbd.,MCC 8 Panel6oards . . � - .. � - . Q-266 Amp.Under 600 V � � Signature 20F-14W Amp.Under 600 V � � o�e�iaoo a�.o.ove.vao v 4 1 6�.2 Ft Exemption for Reg.MainL Elect. #• •C , SINGtE FAMflY � � Temp:�Power Pole-8 App�rrtenances �� � � FFOME OWNER-BUIIDER DECIARATION Sign with One Branch Grcuit ����6�� d ' 1 hereby affirm tFwt 1 am exempt fram ihe Contrador's License Additional Sign Branch Circoits - - - taw for tbe 4oltowing reason (Section 7031.5, Business ond � . � �s a �f}�„j V�, Professions Code�: . - � ❑ I,os owner o€the property,will do the work and the . M�fc.Coreduits&Conductors . p'],����'j� � . str�ciure-is-not intended-or offered for-wle-(Sectinn-�� Qfher(See Complete Fee Schedule)_ . � � 7044,Business-ond Professions CodeJ. -��-�� - - �� CONSTRUCTION LENDING AGENCY - � . • I hereby affirm thaf thare is a constwdion feriding agency far . _ - � the perf�mance of fhe work fnr which.this pecmit ie.issued . PERMti F€E. � .. . . - . . . (Sub-Totol)� - - . � (Sec.3097,Civ.C.). .. � - . - PLAN CHECKING fEE lender's Name .:_ . _. . . //� � � PERA4FF 155U+N6 fEE. ._. .. _ !V - . � � Lender's Address�- � � � � �� �� . � I certify that k-kwva read this applicotion aFld�stWe:3hat ihe . TQTAL.FEE. ._____ ____ .._.. _. . � . (� . ' . obove infarcwNon is correci.I agrea b comply with�all Couqty- . . Qrdinances and Staffi faws regulating Eledriml witing,and . . hereby aythorize representatives of lhis Counry to enier upon . . - � � -the-above-meniioned opsrty foc inspection-purpoies. .. - ����y/�"���� S@E REV�RSE FOR EXPIAfiJATORY LANGUAGE Signature of Perm�tee Date � � � �s .. m� ' �- m L N C,� �p � � V�` ?,C �l� ' � . , � . - _ . "�?-�'� � m� � a �am a .� a'" m �t.mc ' •- ,u`L o N�o wo�`,mvoi m,�'z �`Q U ao �3 m.c o Q:3 N c s ^ �mamc ��p wm 3 �;p� c-�p.p3-` ,r O C j"O..O QI N C O C � N � 'O- F- � O m` E C� . , . . . , . O y,.� m p-G L'i. ..C.. 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