HomeMy WebLinkAbout1680A (10) 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
{ ���'� !
� SignatureofPermiflee-. Unfe �- - - � - - - � -� �-�
i
.. .. o v_ `
^ � a c..t'� � a �3 c ���O �-
;, s Nd '�m�+3� � 9c.� o � °` !^ m � c.t
�o� ."'�c�_ ` o.°a mo c �i aoNa-noa �
�o ; oo'" yo�dm�nms $ v a� �� m:c
.« m�-v .n
. .. C C C�,-0 C O C C.�O «� � �.F � O � dp C � �.1 ', , .
. Q � a �y�� dapC�V ^ .�., w C'Lm� $ � „ , . . . ' � � .
u- Em � � > £ N om � � � P ;
. Z m� � p.n a � E � � .c o =o,°b o v o y o a:o
Q , .c�a � � m n.o,c Q.p �w o c a i••
�°-N« m�"..N o + .r_�vu t a d a °-�.
v
� ~ 004� w ��c� m > m �3m �� �� oi-m
g'� ,� a �� ., ° ms� em £ ' -�o��`°m�»=., t� a
l� a�''�" +° E pq-"a� a- , a.. a+ t�m `"- o-° dr,
� ' p�� .d �m 6 o a=�o � c � c o'e7 o a�a� L „-+cb„�, u , C � : . . . �.
� . ��� j .s� �V.e�l I( �,O` O ''�.�.�fl O N .�,. a''t"' O O „� � N , . . ,
wn a u N °.„ Q e ° °-" + c�° t '�° '�i ''� `' �
£= h. � o� c � o � dti�c- ti m m ..
' , , �. ,o o C�.p �+�y.�a.S„ �4 0 ��.y,�Q� �.> m�i � G °' . � . .
m o� N�°ac.�, c�ow qp, c � c3Eo,�� ; n ' s I�
.�
:��' r �.. � �.� u w�t"IS O� .. � N ✓.� �R�r. O� - p-:'� p � � .
�
. z . N' y r��' 't>^ '� �] p� � �pi d�.. p. �` .�" . . . .
�, �4.� �'C a o N+� �� c �$:c �.r e v x $ E o,-ro ' X. c) d ,
p , � ;, � a.ea.c-..2S.ou �,b��ur' u5�� ��- m a m 3
o� o c,,.L s'6�r` o �-Q p ?�j.°'�� m.��' E as a �
', �, mm.;g„� QaN�� pa„ � „ oo `�.�Q Q � Q o
!i � �, 3"� c'�ic � co avmi � ; tE �� ~ .
! s ���m 4 Q.Eu° °n'v�i°� u-o �"�
�
a . Z
4 �
� P
N j'J
v
Z
E
r �
Q �/1 C
O �
�
� �
�
,{ �
i p 0
! N W_
LL
� � � � Q � � �
a a O
� � � 0,
$ Q � Z a � � z � ,
� .., � o�c � � g � " � .,
,
. �
,