HomeMy WebLinkAbout1662A � � WORKERS'COMPENSASION DECIARATIQN 76a663 t0/ei APPLICATION �QR ELECTRICAL PERMIT
i hereby offirm that i fiave a certificate of conseot to sel4 ��G � . �
insure,or�certificate of Workers`Compensarron Insorance, C4UN7Y_OF LO5 ANGELES____ ______. BUILDING ANQ SAPETY
oi a eertified�mpy-shereo€(Sec.-360Q;-_Eab:C.).. -. .- _.._. -_.._._ .. .
.P�ot,�y o:C2277405Q•qm�„y=j�1]A_ r•oR�vr�iuNr to Fu►iw �oe
.artifled capy)s hereby furnished. New Resideniial 81dgs. al ��+ �JO. FEE . ��RESS
- --Certi€ied copy is filed with#he eo�tMy$urldirtg mspec- .�1&2-FumitY,$q, �_ E — t LQCACI 5 �
�tioe departmenL - � - . .�' Multi-fumily Sq.ft. - — NEARESF � - � .-
� � ��� �� Residenfial SwimmFng Poo4s � � CROSSST.
Date'J-2�-R5 Applicant R' -NY`CF.F F.C.'t�Y"t'RT(,' owN€R OR
FRM NAME
- � � ��CERTtFEf1t7E OF EXfMPFtQN FRpN1 V✓ORKERS'�� � �MA C - - �- �
� �. '�COMPENSAFION-tNStlRANCE-- - �� � Qutlets:Rec_Light_Sw.T - p
Thta sattion naad not bo eam Istad Ff Ihe work iavoivad b first 20 •
�. . � P . _..._ ._. Y Total No, CJTY , . . � Tel.N 1
fhs�permEt is for�oas bundroii dollert-(�1(Wf or-liss.}.. ... Additional - -
�� I certify thaYin the performance of rhe werk for wh�cfi rhis � qp�1p`j�TK .
� permit is issued,I sha41 not employ any person Tn any manner ' - �
� �so as to-be�ome subjett to the Wwkers'Compansafiort I.aws. li9hting Fixtures First 20 - ADDRE55 -
� Total No. � �ifional . .
CITY��� Te1.No.
�� Dafe � Applicant `� - � Fized Appliances Not Over}HP p�µ�r ' -"
N6TICE.fQ APPLtCANt��lf,-ofter mok�iog"this Certifitate of �
Exemptian,�yoo skau4d become subject to the Wo�kers' Rpnge_Heater_D.W. — APPLICANT �� ��
Compensotiort pro�isiaru:,of�Yhs-��Gode,-you-muat#tuth-- _Oven._Dryer _W.M:— �- A��RE
with comply with such provlsions or this permit sha8 be Top _FAt1 —W.H._ .
. deerned reroked. ------ _-_-...._.._ .. Hood ._ qTY • teL No.r74�'-�Q6�
� tICEN$ED GONTR.4CTOR5 D€CUtRAT10N -- , —Fan Other—
� - Disp. _Raom Air Eond. _ R�E�GNN�MgER Clas .�
1 hereby aKirm that t am iicer�sed und�pmvuioin o#Ghapte�9 - �
�. - (commenci.nc}�w�ts-Secz�.7(190��0€Ririsbn3-al-�Susir+ess DtSTRICT NQ. - PROCESSED BY
prtd Professions Code,a�my ficsnae is in full farcearxl-elfecY. Power Apppratus&�Farge Appliartces � .
. . . . .......... . . . . . Size 8 7ype HP.KW.KVA,or KVAR � �� � Q
. ticense N�m6e.Q2Q�Q,H Lic Ctass C-�� - Up to i 4nc1. � . - FINAL � V
MlPr+t�ri[�. � � - Over t ko IQ Incl. DATE ��.„�,.:� YALIBATION Q
Contrxtor Uote 7-22-�5 Over 1Q to 50 Incl. � . . �.rv, .
FtNAI ~
�. ❑ t am exempr vnder Sec. � - Qrer 50 to 1QQ Inc. &Y.� . �
- B.&P.C.for this reason � Qver FQO - �
. � Daie. � Services,Sw6d.,MCC 8 Paneikwords �. - � � -
.. - � D-2f10 AmP.Under 600 V �� � �1 E}�i�A
��---� , S"rgrwture - 2E1Y•t0p0 Amp.Under 6pp V _ - -
' ❑ .� � - . ---'Over 100Q Amp.w Qver 6pQ V .. ��..� • •ti 2
Exemption for Reg.Mairtt.€fect: -
. � SWGIE FAMIIY .. Iemp.Vower PoVe&.Appucie�ences .'.• � C�5�
� HOME OWNER-BUItDER DECIARATION g�gn wifh One Broncb Circuii .��i
- 1 here6y affirm that I am exempt from th¢Controctof's license . .. � �����
.�. Cow fw the following renson(Section 703L5, 8vsiness and �ditiortaF Sign Bmnzh Gtrcuits - - . -
.. Professions Code): - . Q 7.2 J�� '�J -
' ❑ t,as owner of ibe property,wiil do the work and the Misc.Conduits 8 Canductars � � - - �-
' . - structuce is not inte�ded or offered for sale(Section O[6et(See Compfete fee Schedulej_ �
7044,Busineu and Protessions Code). _ .
� � CONSFRUCTION LENDING AGENCY � - . � - � �
- I hereby a#irm ihat there is a construction lending agency for � �- �
'�. ibe performance of the work for which this pe�mit is issued pERMIT FEE � . (Sub-Totalj � � -
. � (Sec 3047,Civ.G+. � � .
� � PIAN CHE�KING�fEE . . .. .
Lender'sNome � f� - �
' - � � PERMI7 ISSUING FEE-- - - � - (f � - -
Lender's Address . � � - � �
I cerfify.that I hvve read.this opplicntiQn.and stofe that the � I�TAL FEE . � -
- above information is correct.I agree to comply wiih all Counry . - . -
ordinances and Sto�e�laws regulating Electrical wiring,and . _ . . .. -- � . �
. � herebyouthorize representpfives of tbis Cooniy to enier upon . . � � �� . . � � � - � � '��
the bove-mentio,.n�ad property for inspection purposes. � - �
\y�lX/M (Y_ /�'���__� SEE REVERSE fOR EXPIANATORY LANGUAGE
Signature of Permittee - Date _ --� I
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