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HomeMy WebLinkAbout1683A (10) � N[QRKERS'CQMPENSAFiON DECLARATION 76Ae63 t0/81 1�1 1 he�eby affirm thnt I.hnve p sa��;f��p�g.g��o���t�,;g,# �E-� . . APPl.ICATIQN:�OR ELECTRICAl. PERMIT � - � insure,or a certificate of Workers'Compensation Insurance, CQ��yT-Y QE-L�S ANGELES - BU4LDING AND SAFETV or o ee/rti#ied co,[�y�/t,h.,e�r�eof(Sec.380�0 /Ea�b�.�C.) - - - -� � Po4icY t�NL!P�1�ompany-+�'1 f�_ . . . ..:fOR APPIIGlFT i6ilU IN -�-- J08 . .- . --.,❑ Certified copy is herel�y furn�shed; .. ... . New Residentiaf Bldgs.$ �� �- � -- A� �� �' � Gertified topy is tiled with the courtty buiiding inspet-.� � 1&2-Fqmily;54...Ft.�(�� f.�. — � lf3C3f.Alt3¥.��. �3r�3���.�}� . tion deportment.' -_E +g���.�/{/.�--�.-.e.�-. Muhi-family Sq.ft. eR�S�SF:- ��A .,�tEOnt�J��G EB�--� _.__.— - - _ .. . ��� 41�} �. .. -Resideniial-Swimming Poais-.-. '- - �� QdwNEROR .... O(rX-��- . FlRM IVAME .__ CERTtF1CAFE 4F EXEMPtf�N fRtltul'WORKfRS � ra� _- ` Quslets:��Rso-_ligM_Svr� . -- . 6-.= -:.- ..-.. .. - .. " .. .GL'>MPENSkFfONSN5t1R�iNE£-- . - . ..�- _. . - - _� '= . -- ADOkE55�- •.. . � First 26. ---- --._- _.. _ _.._ .-_. __- �- (Thi!saetion naeA nof bo complefad if fh�wodc inrdwd ky- �. 7ota!No. Additio�al CfTY - _ Tel.N _ - �- tho psmdt ia For orw iwndred deFFors(fF9@}or kas_s:�.:_ - ..._. . -. ._. .- PL4N EHECK - f certify that in.tFa.perfnrmarrca o#4he-work fru-whk3i this . . . .. .. - . - . _ .._. . ... . -� AaPLKAM ___._.. . _. .. . permit is iuued,-!Sha�{not empby cny person-in bny mannec� so as fo become s�bjecf fo"�he-Workers`--f.ompenaatian Laws. C�gMiog Fizrures , Firsr 20 . ADDRESS � - ��... . . Tota�No. � Addirionot .Da1e . .. n_r+_I•� . _. . .. ClTY � Fet.No. NQTIEE TO�APPLICANT: if,_-.�frgf making-ihis Ceniticate af_ Fized:ApPliances Nof�Ovei 7�HP-- �� PERMIT �� �� Exemption, you sho�fd�-becumc--subject kr-tFre-��Workers' Rpn9e�—HeoEer,.._D.W.,_— aH+I�CaNT _ -. _�_______�--__ -..._. � _. Compensation provisiw�s of the tobw.,Code,yexx:inust_forth-_ �� Oyen_�._Dryei�:=W.M:-..�- � . - � � � - � - A�DRE$5 . � -with�camply-wiih��su€h�srsisian��r-this pevmk-shaN be - Top _.FAU —W.H.— deemed ravaked-.:. .. - -. � Hood.�_Fon -`�brhei.� _.-.. __ CtTY.: • - . - fiel:Na. � .._ . _.__ .-..,. t#GfN5E6£QN{RA�Tt�3�ECkRRAT)�tt -` -- . - . _ 11fEN5E1�t . . - .: - - �. :.- Qisp. -_:-komn Atr Cond.�— Class. -� (hereby affirm tlmf I ctm fitensed under provusions of Cfiapter 9 REG.NUMBER _ �_ (commetxirag-arEth Sectum Zf�BU�of IIivision'3ot�ha-$us3ness OISTRtCT NQ. PRQCESSEO BY .. andFrofessiansCode,arx€-rnyticenseisin-fuft#orceondeNecr. ...�. Pa+YerAp{xire+tus.&.La.geAppliances . .-. _---- ____. .__. ... �PC�� � � 3 e �..--�..,,�F/rrX!'� ,,,./� Size 8 Type HP,KW,KVA,or KVAR - �� � - (} � License Number?���:�_��2��!�.�ta Elass�c-LtL_.- � Up to 1 Inck � FINAL � - --. . ..7�i/Gl17'13/f1 j -..� Over f.in LO.lncl. DATE��_�� -'^���� VAUQRTION d � Conhactor�(��J L= 6dta� . . Over 10 l0 50 Incl. � - V � �. . . . . FINAL . . 1 am.eaempivnder.Seb.�- .-.__:... :-_ . __ ___.___-___4ver50�to-t0E3Inc _ _._.____ . $�-___ ��._,_--�--.,�.. . � . B.&P.C.for thi9 reason - _ Over tQ0 , �,� b�3 A Z , - -- - - �e. . _ Services,Swbd.,MCC&Ponelboards � - - �� � . -- �. D-200 Amp.Under 600 V � .. �'�� • • •� "�. - . $igrwture 201-1000 Amp.Under 600 V , - - - � �- - t - Qvar 1Q40 AmA.or 4rer.fid0_1f_... . _.. ----- � • • ( �.']Q � :� � Exemption foi Rag.Aka"r�i.ffeck__ . . _ _ _. _ .., _ . .. ._. ------_. __. .. �' . SINGLE FAMILY - Temp.Power Pole 8 Appurtenances - ��••Y 7,�?a� � �i HOME6WNER•flUIEDERDECLARATION _. �gnwitbOn�Breuch£Kcait----- -�- -- -----. ... -----. ..O-7�'�:J"HS .... ---- ------ .__ ___ 1 hereby affirm that 4 om exempt from the Contractor's License ,��t�ortaf Sign 8ranchCrrcv3fs-- -- -- � �-- �- tow fw th�foltowing redson(Section 7Q3t.5, Business a�d�- . - � � . - - � Professions Code}:- ..�_. . .-. � - '� �- I,as.owner�of ihe o-er wwll do ihe work and 4he M'� Condv'rh&Cortdoctors-- , - � P �� __ Otirer-See Com lete Fee Sc6edule - i ---ttrudure is nnt intended or offered#or sa1e.(Seclion _�___ P . J— .--_�- -�- . -- _ ------: - - ---. ._- - — -�--- -- � � �704k.Business and Pwfe;sions Code). . . ... .- - .. . � �� _ . -. -- , . .. ..:__. _ . _ `-,�. .__. _._ _ _._ _. ... _ _ .._..._._ . . ..__ .._ .. . ` - CONSTRUC710N lENDiNG AG€NCK� � - -, !hereby affirm ehot there is a construcriort tending ogency for .,_ . '� � the pehormance of the worlc for�whickthis perm�f is issued - PERMIT PEE (Su6-Totaf} - � � '. (Sec.3097.Civ.G). �. . , ... . .._ . . �_- . ....-. _..___ .. __ .. ._ . . . _ _. . .. . __ . . ... . _ . _. . - . . .__. _: . .. .. . . __ . _. . PLAN-EHECKlNfi-FEE_- .. . .._---....-----` -- ..... .__.. . ._ . . ._ ..._. .__.. le�der`sName _ .:_. _ ...._. ___. . . . . . .. .._ . .. . ._ -�.... . .:. ..... . . .. _. . �R������E ID Lender's Address --� � � -��- -- � - : i�7A[f.EE __ __ _ _ ._ -. _ __ _, I certify thaf-1 have read�this oppGcatitiw ornt sbte�tirot ffie� - � � � . above informaiion is correct.t agree ro comply wilh all County � � ordinances and�Srare lows requlating E�edrical wirinq,and -.._ .__._... . .----_-____ ._ . ._ ._. . __. ._. - . � hereby authorixe represeatativea of thia Counfy ro enfer upon�� - -..-.- -� -�-- - � �� - tha obove-meotia�ed pcoperty fw�nspection purposes. SEE REVERSE�OR EXPLANATOAY LANGUAGE ��t.,..7` �`�1'a�P�`-��d`S - _ �. 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