HomeMy WebLinkAbout1680A WORKERS'COMPENSATION DKtARATION . 7CA663 10/81 qpp�,fCATIOR! FOR�ELECTRICAL PEltrtAlT �
i hereby affirm that 1 have a-certificate of consent to.�self .CE-B06G �
cnsure,or a certifimte of_4Vorkers:Cnmpensation Insurance, COUNTY OF LOS ANGELES BU{EDING AND SAPETY
or u ceriifiei�l7 copy the/re�[o�f'((Sec.3600''�,ta�b.[Cj.) - � . -
.��Y h�yZYr��J-F-LL62G6mpa�Y��lf � fOR APVLICANT TO F{lLllt� !OB .
Cartified copy is hereby furnished. New Residential Bidgs.&Poois �� �� FEE AQDRE55 � '(y��g �
- �rrr��� LOCALITY
�ertified copy is filed with the county buitding insper 1 8 2-Pamily,Sq.Ft�7� S ` _ $ TR 35581 . Diatr�d Bar
-tion department �� -� -,�/_- , Mulfi-family Sq.Ft. �R�SS,TT `
7 �.���... . ReSidentipi Swimming Pools OWNER OR
{late...�C�APPliwn2 --- . .
� -. _ . - FIRM NAME �
. CERTlFtCRTE OF EXEMRf14N-FROM W6RKER5' - �MAII �
Ootleh:Rec_LigM_Sw.T �
-COMPENSATION INSURANCE First 20 �R�
(Thit�ectlon n�sd�wt b�temg{tfad M tha.rork lnrolva#by Tokrl Na Addct�onol efp' '�rond Bar Te� �818-967-95 1
tha{wrmM i�for one hu�rrd dolfcrs(�t�)or iasx�j'.
I ce�tify that in the perfa.mance of the work for which this A�4C�E N« _
. permit is issued,-1 shatl not emptoy ony person�in ony manner -
- so as to became su6ject to ihe Workers'Compensation lawe. Lighting Fixtures Eirst 20 ADf}RE55
. . . . � � � Total No. Add�tional
. Date -opplimnt � -'. CtTY . Tel.No.
� - NQTlCE FQ APPLlCANT: tf, after making this Certificate of fixed Appliances Nof Over 1 HP - PERMiT �� �� �" - .
Exempfiort, you shoold betome subject to the Workers' Rpc�ge�Heater—D.W._ ���NT
� Compensation provisions of the Labor Code,you musi tortb- Oven _Dryer _W.M.— A6DRE55 �
� witb comply wifh s�ch pravisiorrs w This permit shal( be Top _PAU —W.H._
� deemed�euoked.. _._.-. . ..__.._____ __.--.---.. . ' CIFY � �C-.'.1�.�.�FeI.No...
iIGEN$ED CONFfFAGTORS-dEC{ARpT10P} .. Nood _Fan __Other_ -
Disp. ._Room Air Cond. uCENSE Oa
'.- . t hereby aHl.m.thot.F om licensed under proYisions.o£SJiapter.9_ __ — aEG.NUMs€R - Class
� (eommeneing with Seetion-7Q4Q�ce4 fAvisiort 3:of the�8crsi�resa QtSt'RlCT NQ � � PR�SSED BY ..
anc}Professions Code,and myffsenae'rs'rn.fv4t ��y, Power Apparatus&Large Apptiances - }
[fQ - 5ize&Type HP,KW,KVA,or KVAR � a
�- Litense Number��J1L_.-.Lic.G � Up to t Ind. FfNAt - . - V
yr/�^`r�rJ�i �Q('"� Over i fo f0 kncf. 6ATE� l�- �� VALtDATION . �
ConhactQr L( F .Dnte LdL � .
❑ Over}0 to 50 Inct. F
fIFJAL
I nm exempt under Sec. Over SQ to 4pp Inc. 8V t�------ . . _ W
� $.BP.C.#ar this reasan=.-- Over lOQ t�'il
. ..... � .. . $ervices,Swhd.,MCC�&Panetboards � � �
Oate: 0-200 Rmp.Under 600 V _
Si nature 2(7i-1000 Am Under 600 V -
� g Over�WO Amp.or Over 600 V e 1 b 8 G A
Esemption for Reg.Maint.Eled. . �� � � • •2 .
', SINGtE FAMIIY. Femp.Power Pole&Appvrienances
� . -� HQM€-OWNER-BUILQER DECIARATION-- Sign with Qne Branch Circuit � t c� �`���5 C+�
_ 1 hereby affirm that t am exempt from ihe Cnntracfar's license qddi�ionak Sig�Branch Eirc�its -�- - - . � c �
- Law for the folbwing reason(Section 70.?1_5,.6usiness and c c s� „�;�� .
Professior�s Codej:� � � -
❑ ..I,ns.Qveae�af.ihe ra r �wit!-do Fhe woFk and the Misc.Conduih E Conductors - - O�I.£J�"��
P ��� . Other See Com lete Pee Schedule_ � � �
. structuoe-is not intended or offered for soie(Section f R � . ) � .
7044,Busi�ess and Rofessions Codej.
CONSTRUCTION FENOWG AGENCY . � -
I hereby affirm skmt.fhere:is atonshudion.lending ngency for ._ __ _. ___.._.. _.. . .
tfie performonce of the work for-which this permit is iuued pERMtT fEE--- - --- � � � - (Sub-Totolj . � �
(59c..304T.Civ..C.}. .. . . � .
� � � - � FLAN CHE6KlNG FEE � .
� Lender's Name - -_. � �
. . ..._� __ . . . . . PERMIT ISSUMG FEE . . _�-. ...... _. Q .. ..-.
� Lander's Addreu �� -� � - ����-� - �� - -
(certify lhat!Fwve read t6is opplicakian and.stafe�that the TQ7Al.FEE s .
� above information is mrred.i agree to compiy wirh all Co�nry � �
� ordinonces und State.faws regvlming Electricol wiring,and . -� . �-� .
_ hereby authwize representatives of Nris County to enter upon - . � ��
_ ih bove-mentioned properly for inspection purposas. _
,1 - --- - SEE BEVERSE FUR EXPl.ANATORY iANGUAGE
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