HomeMy WebLinkAbout1646A (9) WQRKER5 COMPENSATION DECtARATION 76A66a toi9t qpp�{CAT{OiN-FQR ELECTRICAL��PERMIT- � �
I hereby af€irm that f have-a certifimte of consent to-setf.. .CE-806G
insure,or o certificate of�Hwkers'Compansatio.i Insurance, COUNTY OF LOS ANGELES BUILDING AND SAPEFY
or a ceriified-copy thereof{Sec 3800,Lab.C.) _ � � 'I
P � �Cy eL',�77405(3 Compony �� �. . _ _ . FOR APPIICANt t0 FIt41bl -- JQB ; - �
� . . Certified topy is hereby f�m�shed._� �- Ne�Rea�deMial 61dgs. ��� ��` - ��� �R�
- Cer+'rfied cepy iafiVed with the coontq boildiog irtspec �-�g 2-Family,Sq. f — E LOCALI .
tion departmenf. -�-i - � Mulh-{am�ly Sq.Ft — NEAREST */ 1 �
F .- - CROSSST. O`'►'� .
+t �� �� . . .Residential Swimming Poots � OWNER OR �
� Qale–f ��'�3.-. �PP(ica � L' . .. FIRM NA -
� -;...CERtFFtCAfiE�t?F�EXEMPTtON-fROM�WORKEAS`.. ..-.. .. Outlets:Rec_Light_Sw._,_ .... .� � ...- Il
- COMPENSATION INSURANCE � Ao�REss
i (Titisa�sfionii�awtba-Complatodif thewodc i+tvolve�4y-. FirtY 20 CITY • T
thv parmii Fs for oa�hundrod doklnn(�t00par tau:)�-=�- -.Tatat Na. qddifionaE –
1 ce�tify thW in the performance of the work for whith this . - - q pNj qy�
. permfl 7s issued,I shutl noF empiay any persoo-in doy manner "� � - � � �
sa as to become subject ro the Workers'-Campenaation Lows. Gghtfng Fixtures First 26 ADDRESS - .
� ' - .. � . � � Totgl No. Addilional .
. .. . CIN Tet.No.
- Date Applimnt - � fiaed Appiionces Not Over t HP PERMIT
. �NOTICE F6 APPt�CANT; if, aker making fhis Certificate af - A��y� � ��
- Exempiion, you shouW become subjecf to the Workers' Range_Hearer_D.W.—
. Campensation provisiorrs of the Eabor Code,you must�forih- Oven _Dryer _W.M.— ADDRESS���-
. with tomply with such provisions or this permit shall be Tap � _FAU —W.H._ .
-deemed revoked, - - � Ha� _Fan _Otfier_ CI7Y . �TeI.No.� _
_ - LICEN$ED CONTRACT6R5 D��LARATIQIY . � ucFNSE R
i hereby afflrm thaf{am iicensed vndac provisions of Chapter 9 Disp: _Room Air Cand. — REG.NUMBER Gass.
�- �(commencing-v.iih Sectian�_7Q44�.Qf�Divisiort 3 aE1he-Busmeas D�STRlCT NO. �� PRf}CESSED BY r �
�� ond Profesvons.Code;�and my license is in fuU fwce oad eHect power Apparmus&Lorge Appliances y
� -- � - Size 8 Type HP,KW,KVA,or KVAR
Q
License IVumber 42n7� Lic ClassC–�.a - - up to t End. FINAL `� y E� � V
. .. 7"�2�85 Qver 1�o i0 tncl. QA� 4 .1��v, VAUIIATfON �
Controaor��rj-C3�- t?ate Over 10 to 5Q Ind. fINAt ' U
� _.❑ !am exempt under Sec. Over 50 to 100 Inc BY �
B.&P.C.for this reason . Over ifi0 . � ._ _ a
- - Services,Sw6d.-,MCC-8 Ponetboords �_ - Z
. �°�e' - 0-2QQ Amp.Under 60�V
Siqnature - � � 201-tODO Amp�-Under�60Q V- - . �
OOver 1000 Amp.or Over 6Q0 Y � � -
Ezemptian for Reg.MainL Elect. ����7�,b A
� SkNGLE FAMILY Temp.Power Pole&Appunenonces � � �
-- - HQME OWNER-BUILDER�ECWRATIQN � #�'�.' � •`� -
Sign with Qne Bra�+ch Greuif .
!h�reby affirm[hat t am exempt from the CoNrnciar's Lice�se p����ono4�Sign&anch Circuits � . � ._�
� Eaw ior the foltowing reason($edion 703}.5, Business and .� �����3r O
.. Professions Codef. � �
❑ t,as owner of the ro rt will do the work and the � Misc.Condui�s&Conducrors - � � � d�3.v 0 c=�,
� P � Y� Ofher(See Complete Fee Schedule)� �-
, .structure is not intended or offered for sale (Section �7�Jc_$Jr.
� ._ T044,Business and Professions Code). ,
. CONSTRUCTION LENDING AGENCY - . � -
� I hereby affirm t6ot there is a conshutfion(ending agency for � �
- � fhe performance of the wo•k for which this permit is issved PERMIT FEE - . (Su6-Tatal) . . .
: (Set.3097,Civ.C.j. . � .
� � PLAN CHECKING F€E� . ._
- Le�der's Name
� - PERMIT ISSUIIVC FEE � -
Lender's Address � �
i cBrtify That I.hove read this apptication and.staie that the fQTAL FEE � �
- above information is correct.I agree to comply with aIl County � �
� ordinances and State laws regu�ating Electricai wiring,and
- hereby outhorize representatives af ihis Counry to ente�upon _� �- -
ihe bove-mentioned property for inspection.p�rposes.
SEE REVEBSE€LSR EXPIANATORY LANGIJAGE
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