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HomeMy WebLinkAbout1693A (10) WORKERS'COMPENSATIOPi DECLARATION Tbq663 ��iei APPlfCAT10N FOR ELECTRlCAL PER�VtiT � I heceby affirm�that I Iwve a certificoie of conse_nr to self CE-806G insure,or o certificaie of Workers'Compensation Insurance, COUNTY OP LOS ANGELES BUfIDlNG ANQ SAFETY or a ti i copylhereo�(Sec:3800 Lob,C. -.. . - Po�� Company� FOR APPUCANT TO fftCiN � Jp8 Lj Cerhf�ed wpy is hereby-furrushed.- New Residemiak Bldgs. P E4CJi� NO- �{E ADDRE • �-� � ,j:erti4ied-copy is#iled-w'rth ihe cou_srty bu'rlding_'tnspec-... T&2-fnmily,Sq.Ft.� s ' = 5 LOCALITY � 35581 Dlffi[nl'� tian de trrtment. ...u . ��. .:__ � Multi-famiiy Sq.FT. NEARESF j���f� Resideniial Swimminq Pools CRO55 5T.__,,,-_(„� Dafe �. . . PPIiCb�t��['� 7Y � . OVJNER�OR . . � - FIRM NAME� ---��-CERT4FtCA7E`(7F EX€H{�'ftptV-FRpFh-WpRKfRS'--� - Outteh:Rec_Lfght_Sw._ ���� � COMPENSATION INSURANCE ADDRESS. . (This tatfion nead not Iw cumplotal ll-tlw�wurk 7wrolv�by � - First 20 � tlw permit€s Eor oae burtd�d dollars(�IOOj-or f'ss:)�-.- Totat Na. Addit'ronal C4FV � . Tel.No� - � �j41 PtAN CHECIC- F tertify tFot in tbe performartce af tha work for whith this A��M - - permit is issued;t sball�not empfoy any persop m any manner � � . sa as ta become.subject to ihe Workers'Compertsatiortlaws. lighting Fiztures � - First 2Q ADDRESS .�.... .... . -..- . Totol No Additional -- _ ._..___ CITY Tel.No. . SMte --- �.,=Plicaat - � .r - - ------- ----�-- ---_..- -- .. NOTIGE TO APPLIUNT:�If, oNer mukrng-tbis Ceififiicate of - fixed Appliances.NQt Over i HP PERMIi � , _ Exemption.�You--.shoufd:-became'-SUG(eE�ts-the'�-Wflr#ers'.. _Range_Heater_�6.W.--. .. - . .... ...- �. e_ ....- � � Compenmsion pravcsEons Q#-_the ta6at.Cad�.Kosi�.musl forth-.� Oven��_-Dryer-.._-W:M�--- .. .� AD�RESS . . . . . .. P.Q. Bca 1111 � weth.compfy�.with wch{uoviswns ar thn permif��shaU be 7op..._..�.—FAt} —W.H.— � _ =-- deemed revoked-. � '-�.- ..... . . Hood _..Fan _pther_. . CITY . � Tel.No.- _� UCENSE�C4NTRACTORS➢ECLARA710N .. tFCFNSE�R ..� 1 Eiereb affitm�tkwt#am licenset#vnd�r ._.-- ��P-_._._.._RQsten_Aic.Lond.�.��_..__.:. .. �e y -Prou+sierreo€€hapter9 . _. _ .REG��h:U�NBFK . _ . . -. �: .Class .. - (commencing u€ith-Sectlon.T(Y1Q}of l3ivisiee�.t 3 tr�-tk+w-&�«ress- � . . . . ..----- --.... Se Power A. Qt�s�L iances _ Dt5TR1CF"T+lO:- - -- PR6CESSED 9Y a�d.Praissslafts.Cade.aAdmyJicensevsinf�rki�forceard-ef4ect: -.. �°f °�9e-F+PR� _. _. . . } fi Size 8 Fype Hp,KW,KVA,or KYpR /Q � � license.Number!���[(1fy��Lic.Clasf�(I , -- � Up to t tnci. . . . . .- -- . .. fiNAL . .. . _ . . � __. - U ... Contracror�lj'-"t .r-�-/��IJC�Date�� t�.. -:�� �ver t-to t0 1ncf.:- . �.. .- :_ - -_� 9F4T€�-�_����'^�r Vkl16Af10lt - ��. z .. . �- ,-.-. .. �. _.� .. . C}rer:.i4 Yu�`Q.tack -. __. , . ❑ �.� �...... . FFNAt -.::_ ._. . -.,. . I om exempt under$ec. Over 56 to 106(nc. gy G'2-_ W _- B.SP.C.for this reason Qver 700 y . � �1e: ServFces,Swbd.,MCC&Panef6oards �- , ? - � 6-2O0 Amp.Under 600 V � � .. .. Signamre - - 26t'-i000Amp.Underd(30.V. .. ... - � � . ._. _-- . _�_. ... .. _- __- ..__ ___ -_._ {7rec�7000 Amp,ei-4ver-690-Y. ._ -- -.. �.-._ :-_�,: __ . � - - _ �i69,3� _ Exemphan for.Reg.Mainf_Elec�, -.- .... - -- . -- ._.. _ __--- ` -_. ._ - - - -- - - - - - - . . . . -�__ .�_ SINGFEFRM4EY ...-- ,._:_ 3emp.Pnwer Poie 8`.i4ppurxenadtes ' .._:_ . . -. ._ ;_._ ._.-.._ , -:.: .�-.�=e s;r-r-�...�,_ _ . - � F!f)ME OWNER-BE116DER DECtARAitL7N Sign with.One&oncl+C�rca�s .:. - . ,-: -.. .... �:- -- _ -. . 1 here6y affirm thot I om exempt from the ControUar'alirxnte � _ . _ .. _ � j •_�f1�j(Q ... law for the€otlq.v"mgreason-.(SacHort 7€S3F.5�-6vs�rress arrd --.. Adt}dianal�S�ga.6eontk£ictum_:._ _ . . --�- --. _-,-- - -.. --- . .. � Prafessions Cade):. ._ .. � . . . . __ ._ . .. ._ _... .. . �.•� e/j.�v�-(��� --� . :,� � .._ _ .. .:.:_ . :_� _... AMs€.Eondnrh 8 Corrdurtors ._.: _. �_ .,- _. :.-. .-... .-._. .._-- �.� .: ...1,as ow�ner o#She property,will-do the work atxl the � -. D 7 2��8 5 . -stlucture is-ool intended�w offered-�tw sale{Secdon ��- �#her(See Comp�ele-Fee Schedule)_ � . . . :_ :- -- [— - s�. ,s .[:.- _ _.x. __,- -. . . . .7044.8usmess aruf Vrofessions Code}. .� . ..`_ . . . .: . . .. . . . .GQNSTRUCFIQN-:LENDlNG.A6EN�Y � � - --- .--- ---------- _-�:� _ .'::. ._ .. - -. - ..-... --�. . ... . .. .. .. . ._ -_- _._`. _..__ -_.� . _�----_. ._.. ._-- ---- -- - .-- -- - t here6y afftrm rhqt there is a canstructior5 lending ageRq for - _ � � _ - � � the performance of the work for whicb this permit�is iss�ed -: pE{2NUI#fE� --.�.' � - �. _� . - � - `--- - -� - (Sec.3097,.Civ.C.y . _ .. . _... _. � - _-�.�. __ ..{5ub-istat}_=.: ., �.� . - . . . ._ .--- . __.. . . _-. . - - ._. � ._. . .... . PtAN EHELY,�NG-FEE...._ ..__. .-- � . __ .- -- -- - --- -- Le�der'a Name .. .._. .__. _._. —_- ._ . _._ ..__ . . . _.. .-- __ �� pEBM1I_ISSUTAIG Ff€__ _�. ---- �a:. ._ _-. .. . ._ __. .._. . _ _ .. ._.. Lender's Address - � - � - -� - � �-- -- -�-- -� -- � I certity thal 1 have read this ppplimtion and stote that the TOTAL FEE_ -� � - �,�� _ � � _ . ,- .-� ------ --. -.�. . . . . ... .:._: . ._ �_�:. . _ .... . �..... above information is correU.-EagrBe W tompty�wiFh atl Counfy � - .. - ... - - -- -. .-. . . . � __.. __.-.�. ... .. wdinances ond Sfute laws regulating Eledricot wiiing,und . '... ...�.... . . '.---� -. - ..- �-� .- �. -._ ..- . .._ . hereby aothorize represenlatives of this County b enter opon � - -- � - - � _ � - �- the above-menti�properry for i�pect�on purposes. ;EE BEVERSE FOR EXPCANATORY LANGUAGE__ �� l..T - '�'j��'1"�,r�r`����� \J'l.R,� � Signotore vf Permittee -� �ate.- ... . -----� .,... ..,. - _- . ... ,;, hc •' � v �� oom�° ,o�,L; "• �� ��' o" Oa�' a QmN � a,tm u�o3cyao ; o-umoc � coy ,�'. � c-c 6�"2`m`o m c�ci�" m.'c o U° im ° ��^- ° o � oQ �b �, �° e�'aosd 3 �.°'co-°c'�°a� V omu � aoc � > a,—�- � omm rn-� z uu � tM > E „ ceur- r o m.c �� E �°' � .. ��oi°� � oEmEomt o " mt3m $ o � Q Ec �E.��. o..�"..��oy� �`o °� � �oap:fr - ' .� o o ��`� orc, m m > E m 3 m c o � E 3 � � N U a°¢* o E � m,e� c m E '�'o? �,c�t m� � w E ^o � ca+- yQa � h— "' �•.: c ` y , � x�vuo �.�.c°oE o0 oo,mnm '"` o.5n u+ � 3v �yu �v.Mkoo� a� i °� omO+.c.r :.�: p E o ..„ a a � o •• o m.oa o u,.� hs ;� u� c .�. „ 3 � $.. .c e ro o � °�° o'omoo..°�� � t�' ,,. mey >ao3i•:-: v� � � as „',�..�'. � „ '>� �u � ocN� a;roo� y v' m w � ��Ey�M �O'=� aQ.. ; c_= oEa�� ; � = s � � p �...a ...,a,a-=�-.` ��.��: o =' �-� o_o `m a .. °aoo� m+ o$ac �. o� � 'm == E � E� ° :.E` �° �, Nn � a � � .a �-- `u^�u � mm.o�' X cj � a "m o,aN� ,°t� cu .s.m.,n � L"p ?�.,.�°.x c ° m'.'n _ '�, °. m c s W h PL� o � � ? 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