HomeMy WebLinkAbout1679A � WORKERS'COMPENSATION DECIARATION 76A653 10/91 qpp��CAT10N FOR E�LECTRICA! PERhA1T �
1 hereby affirm tFwt f hnve a�certificate of consent to self �'�G .
insure,or a certificate of Workers'Compensatcon losurance, COUNTY OF LOS ANGELES BUILDING AND$AFETY
or a certifie to�fpy ihe(/reof(Sec 3906�.L`a'{6�.}yC1.j � . . . . - .
Palky Nq��a��`��Lj�pa^Y�//�i' - FOR APPtKANT�TO F0.L W . . JOB � - - '�..
DADORESS
Cerfified�copy is hereby Fumished. New Residentinl Bfdgs. -Pools ��H NO. FEE I
. � � t 82-Famil �Ft. ��,� . $ — s IOCJ�UTY .
Gertified copy is tiled��wiih��the�courtly b�ildi��nspec- V;54.
tioa department:- � - MultF-family Sq.Fi.� — NEAREST �
.r y�/J c � Residentiaf Swimmirtg Pools CRO55 ST.
. Oale._�j'�ApR!lcant. �f��s. 9`-� -� OWNEROR � � �
FIRM NAME
- � � � CERTlFICATE QF EXEMPTIQN FROM WORKERS'- . putlets:Rec_tigbt_$w._ ��F� - - � � -
COMPEMSATtON INSURANCE � . - stppRESS
(This secllon naad mt be completed if 1hv work iavoived by Fi�st 2Q � ..
�1w pormit is Fw aw kundrad dulfesc{�t00}-or Ie�a.)-. Totol No. Addieioncil CkiY Tel.No. _ — 41
- PlAN CHECK
t certify that in ihe performonce of�he work for which this - . _ A���� .
pecmit is issued,t shatf rrot employ any petson in any mdnner -
so as to 6ecome sabject to the-Workers`Compensatiorttaws. Lighting Fixtures - First 2Q-� ADDRE55
intat Na. Additional � . .
�Date � nPP4icont . .. . QTY- , � . TeF.No.
NpTICf TO APPElCANT�:�fi;-q41er mo(cing=thirEertificate-af- Fixed Appliances Not Over t HP pERM�t �� �r .
Exemption, you should betome subject to the Workers' Range_Heafer_p.W._ APPtICP.NT. `I'. �' �(,'
- Compensotio�provisimu�.of�tke:Yabwtetde,-yev-.mUst-tartA- -Oven �Dryar —W.M.— ADQRESS - -
with comply with such provisions or this permi�shaEl be Top _FAU _—W.H.— �
deemedrevaked.- -.-:.- ,�__ _____ _,__ .. . Nood _fan _Orher_ " EtTY �(+�yi� re�.�91-6461�
tICEFJS€D C6NTRACTORS DECIARATfdIV �- ����
t here6y offirm Fhct 4 am ticensadnnder-pearisiora-ofLhepter q� �k�.�.—Roam Air Cond — REG:NUMBER 420 4 Ctass.C_�p
- (tommenciag wi�h�ction��OpQ}nf.Riuision3a£-the-&usiness� -� pQwer Apparatus&targe Appliances DISTRICT NO. PROCESSED BY
�and Profess'rons Code,ond my ticense-Is in full force effact. � � � j�. �
Size 8 7ype HP,KW,KVA,or KVAR - � - � �
License Number���'�Lic.Cfass ._ y. . . Up io 1 IncL . __ ____ .. .. . FINAL Fv r-- U
. ��� I/I�'� _JZ�X7�OY~ - Over t to 10 Inel. DkTE �2—!�=O] �
YALIQAT4QN
Coatractor ,$, Date LE](dSLli_ pver 10 to 50 inct. F�� -
�� I om exempt under Sea � � � Over 50 to lOQ tnc.- 8Y - �
__ B,&P.C,for tbis reason . � . . Over 100 _ Z
� ��e_ Servkes,Swbd.,MCC 8 Panelboards � - ...
0-200 Amp.Under 600 V �
Signature ZOi-700p Amp.Under 66D V �
� -f3rer iQOQ Amp�ar pver 600 V - -
� Exemp�ion for Reg.Maint Etect - � � . � - � - � � z� 6 7 G
SINGLEPAMILY �-- 7emp:�owerPoFe-&�Rppu�tenances - . #� •-�.• •�
� HOME OWNER-BUILDER DECIARATiON Sign with Qne Brench Circuit �
1 bere6y affirm thai 1 am exempt€rom the Cantrnctor's license � - 1 -• �eQi�.Jr Cj-
Caw-for the foflowing reawn�Section 703L5, Business ond Additionat Sign BranckCircuits . - �
Professipns Coder - _ � � ! � e b j,J��
� - --- MiscCondWtsBCond�ctors . .
I,os owner of tha property,will do tbe work and the �'],2 y—�5 5
� � strocture is�not-intended or offered for soie (Secrion Other(See Complete Fee Schedole}_ �
� . T044,Business and Rofessions Cade). � - .
. CQNSTRUCTtON�ENDfNG AGENCY - � �
I hereby affirm that there is a mnstruction teoding agency for
i6e performance bf the work for which ihis permit is issued � PERMIT PEE�- {Sub-Total) �
(Set.3047,Civ.C.�. � . .
� . � PCAN-CtfFCKING FEE - -
- Lender's Name -
.� PERMIT ISSUING�FEE- - � - � -
Lender's Address �
i certify that 1 hwe read this application and slate that ihe �T�F�-- - /,SQ . . .
above informotion is crnrect.t agree b comply wilh all County
ordinances and Stota iaws rogulafing Elechimt wiring,and . .. � .
hereby authwize represent6fives of this Caunty to enter upon . - � � �
the ove-mentiane properry for inspectioe porposes: � � - - - -
�}� �� SEE REYERSE FOR EXPLANATORY LAN6UAGE
_S�l����� 7 d -�
� Signot�re of�ermin� se . Date _ - . �
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