HomeMy WebLinkAbout1661A WORKERS'COMPENSATION DECLARATION 76A663 t0/Si �p�L1eATIAN FQR EtECTRICAl. RERMIT� �
� t hereby affirm that I have a certifimte nf mnsent to setf �'�G�
Fnsure,or a certi#icate of Workeri Compensation Insurance, COUNTY OF LQS ANGELES BUIIDING AND SAFETY
or a certified�copy thereof(Sec.38Q0,Lab.C.) - �
Policy No.�'_2�774d5�'.amparry,�� . . . FOR APPLKANT TO FUL W- . . JOB
..n ertified-cbpy is.hereby fnrnished.._ _._.. _ New Residential Bldgs. EACH NO. FEE ADORESS ' •
. S _ S... LOCAL -__ . � _ _.
- Gertlfied copy is fiFed with the county building inspao- 1&2-Fomily,Sq
. tion deportment. - ��- - � �- - - --- -� Multi-family Sq.FL � — NEAREST � �
Residential Swimmin ROols �R��t Sf.
�, . date 7-22—�r3 a�i��an} �",t•�' Mrd'r3a Flort�r�C Q Owt�EROR �
FIRM NAME
� � CERTIPICATE OF EXEMPTkQN FROM WORKfRS` putlets:Rec Light_Sw._ �-p�� - �
� COMPENSAFtON INSURAM1lCE - -
- This soction t�d�not be e !i iFw work tnvolvad b first 20
� ���� Y Torol No. CITY . - Tel.N
��. . the ptrmlt la fac aae hund�gd�aI{arc(�14Qj wlw�..j.. Addrtional . .
. 1 certify thai in)he performance of the work fw which this � p�pp�N�pry� � -
� permit is issued,I sFati not emp4oy any person in any manner
� so as to become svbject to tbe Workers'Gampensotion Laws. ��ghting Fixtures First 20 AD4RESS � �
� - � Total No. additivnal -
- �ate �� ATPlimnt � ... � . CITY TeL No.
- � NOTlCE�TD APPLlCANF: If;-after'makin this Cer�ifitate of FixedAppliancesNotOver i HR pEgM�T
� Exemptiort, -you�shovtd become-svbjecF�to--1h�--Workers' �nge_Heafer_D.W._ � AP���`�f � °
� Eompensation provi5iarrs of ahe tabor Code,you-must forth- Oven _Qryer- _W.M._ - AUDBESS
with.compFy-witk�wch-fuarisions.ar.ihis�permtl-shoF46e�� . .Top. _FAU —W.H.— . .
u
deemedrevaked.-� �� � - � - Hood _Fan _Otber_ - CITY � Tal.No. �
- � LlCENSE�CONiRACTORS QECLARATIQN � � LICENSE OR
�� 1 fiereby affirm thot t am Iicerised under�oris�or�s af Chppter 9 Disp. s Room Aie Cond. — REG,NUMeER 2 �]4$ � ��- —
� - {tvmmersdng with Section 7dW}of.�ivision 3 af the Business Power RpparatusS lorge Appliances - 6tSTKtCT NQ. - - - PROCESSE BY �,
�_ � andProfeuionsCnde,arrdmylicemeistrtfutlforceund-effect. . . � A
� . � . - �-� � . Size 8 iype HP,KW,KVA,or KVAR� �- � a
. Cicense Nvmbet -� ���?�Q� Lic.Class �`r.j,Q Up to 7 Ind. FlNAL . . . �
�C�t'yf'� Oate 7?— �i �er 1 to l6 IncL � DATE �.y=��. � �
� Contracror k'7 E'�`� _,� VAL�ATIOH O
Q �7— $ Over 16 to 50 IncL FtNAt ~
!nm exempt under Sec Over SQ to 100 Mo BY Q
- 8.&P.C.for this reason Q�ef�� Z
Date: Services,Swbd.,MCC&Ponelboards � -
� � - - 6-20Q Amp.Under 60�V � � z� 6 fi� R
_ _.
.. Signoture , _ - - 201-IOOQ Amp.Vnder 600 Y .
❑ Ovee tOpQ Amp.or Over 606 V � . . #�.� • • '�'� .
Exemption fw Reg.Maent.Elect. . -
. . .� . �SINGLE FAMILY � Temp.flower Pofe 8-App�rterrances �� - � • j�C���
- HOME OWNER$UIIDER DECLARATION Sign.wiTh One Branch Cirwit � .
. I hereby affirm thot I am exempt from ihe Cantractor's License ��trior�al-Sign-$ronch Circvits . •�° } G�J�a�
. Law tor the Following reason(Section 70.31.5, 8osiness and � � �
Prafessions Code�: � � O 7.z J���J��
❑ - I,as owner of the ro rt will do rhe work and the � �`x.Conduits 8 Conducrors` . �
P � y' pther(See Complete fee Schedule)_
, structure is not intended or offered fw saie(Sedion � � .
- 70A4,Business and Professions Code). - � .
. . - GONSiRUQION LENDING AGENCY - _ �� � -
� t hereby affirm thai theie is a conshuction lending agency for . �
ihe performance of the work for which this permit is issued - PEkMtT fEE -��- � .(Sub-Totnl) . � - -
(Sec.3097,Civ.C.�. - � -
� . � � - PtAN�CHECKING FEE . - � - . -
Lender"s Name
- . ' � PfRMIT ISSUWG fE€ . -
Lender'sAddress - - � - ��jti �
I cerflfy that i have read this appiication and stafe ihat the TOTAL FEE � ��v �
- obowe information is correU.I agree to comply wifh ail Counry � _
ordinances and State Iaws regulating Efectrica�wi.ing, ond �, - . �
� hereby authoriza represeMWives oF this Caunry io enter upon - � - .
the bove-mentior�ed property for inspedion purposes. �E RFYFRSE FQR EXPLANA70RY LANGUAGE
�����..���
Signature of Permittee Dafe . � ,
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