HomeMy WebLinkAbout1664A (9) WORKERS'COMPENSATION DEClARATION 76A663 ,o,e, � APPttCATtQId FOEt ELECTRlCA! PERMIT
I here6y affirm thot!have a cerfificote of consent to gelf �-8� , �
inwre,ar a certificate of Warkars:Compensat�o�lnsurance, COUNTY OP LOS ANGEIES BUILDINs'r ANQ SAfETY
ara certified'copy thereof{Sec.3800,Lab.C.j � � - � �
�Cy N(y�„�7�4OSO Company �A _ FOR APPLICANT TO Fltt IN -- � � 10B
�fified-copy�s hereby ivrnish@d.�. ... _ -_ � New Resideotiql B4dgs:- s EACH NO, (�E A�DRE55- '_. • lg •
: . ._ .__ _ . . .
_
- - 1&2-Famit F $ — S LOCALITY ,
Ceriified copy is frled wifh ihe courtly 6ui(diog-inspeo- Y.59� _.
- �tion departmeni. -- "- � '�: � Mutt4-fomity Sq.Ft. ^'. NEAREST
� ` n �r Residentiol Sw�mmin Poots � = ERO55$L .
DafeZ—Z�—S`���..4�,I�coni. T ,.I41C� F'C.FY`rprrtr�� _ .g . ... . .�... �. - o�a.� -- :- --. ._ - .. .
- _ _. _ _._..
_.. ._..._._ - FIRA1 NAME
:...:CERTfftGATE 4F.EXENIRIlC7N"FRONt:1R�ORKE85'... . . . . :NwtC_ . __ . __-...
� - Ootlets:Rec_Light_Sw._
. .. ..-CDAAPENSATIOhI iHSURANCE .'. � � ... fiDRRESS �
(This aeefbe nwd-not ba camploEa��#ifwwork lsvelvod by first.20 . .
tf�a p�rmlt is far one hdndred dolfars($iQ0)ar fass.) - Tota!No. Addirtonat qTY . Tel. _ _ .
t eertify that in the performance of the wwk for which lhis � � �N - -
permit is issved�i shall not emptoy anyperson in any manner � RPR��AM. .
- - so qs to become.iu6}ecf to the Workers'C.4mpe�sation Laws. Lighting Fixtures firsf 20 . AQ6RE55 � �
� � Totol No. Additionat '
- pate °PPlimnt .. ClTY Tet.No. �
NQFICE-TO APPLICANT:-tf,-affer�moking�tMs{ertifiicate af Fixed Appliances Not Over 1 HP . PERM�F � '—�
Exemption, you shauld�-become-�subiect to�the Workers' Range_Heater_D.W. __ � A��NT a „ C-F'k-''- �.n. -
. Compenwtion provisions uf the Labor Code,you musf forth- Oven _Dryer _W.M._ ADDRESS � �
with wmply witEr such�prorisions�or-tMs permiE sha41 6e ., _Top _FAU —W.H._
� deemed revoked. � ��� � Hood _Fon _pther_ CKn � � TeI.No.C)t3f��(1
- UCEM1tSEQ CONTRRCTORS D€CLARATION ���pp -�
- -t hereby affirm that F am licensed under provisions of Chapter 4 �isp. _Roam Air Cond. — REG,NUMBEa Clas��].0 �.
� .(commencing:wHh.Sectian-.ZOflf#).aE Qivisi��-3-af the Business . Rower Apparatus&large Appfiar�ces . 6fSTRICT NO�. - PRQCE55€�BY �
� and Rafessions Code,artc!my-litense is in ftt!!force and effec�. - � - � '�.
� .- �� �-��- � �Size 8 Type HP,KW,KVA,or-KVAR� �
', � �tMcense tJum6er QZQ�a��—tic Class f'--10 .... . � ttp to 1 Ind_ .. FWAL � . � �
- - - Over i�0 161ntk. DA K '
- CantractorF:1F�1�1-Y"[[`131.. Dote 7-22 8� � -s.-{>=� `''r'i,'. YAllDAFION . 0 j
. ❑ . . . Over 10 ta 5Q Incl. F1NAL � � ~
I am exempt under Sec.� Over 50 to 106 Inc. BY t�u �
�. . B.SP.C.for this reason �- . Over t06 � �"" � � �
. - - pa��; Services,Swbd.,MCC&Pane�6oards � — �
- - O-200 Amp.Under 600 V -
. Signalura � 261-100Q Amp.Under 60D V � -
� � . . - _Over 1000 AmR.or Over 6QQ V- -
Exemption for Reg.MainL Elect. -�
S�NG�E F:4tv�uv Fer�p.�ower Poie 8 appw�e�a�cas �i b b 4 R
. HOME OWNEB-BUICDER€.�CLARATIOtJ g�9n with One Brancb Circuit _ -- #� � � � �2
I hereby affirm tfiak I am exempi fiom fhe Contracior s License AddNiona�Sign Btonch CiFc�fis �
�.. Law far the fottowing reazon(Sectian 7Q31.5, Business and � - - -- d
Protessions C«te}: �l • 1 0 5 5 d 9
� � Misc Conduits�Conductors � 3
I,as owner ot fhe property,wil�do the work and the •y � (��5�t'��
- structure is oot intended or offered for wie (Secfion �� Other(See Camplete Fee Schedute�_. � � . � - �
. �7044,eusiness ond Proiessions Code}. � Q 7 2�_8$
� CONSTRUCTION LENDING AGENCY -- -- - -
�. i hereby aHirm that there is a constrodion lending agerxy for �
the performance of the work for which this permi�is issued PERMtT FEE - (S�b-Total) . � .
(Set.3097,Civ.C). � - �
�- �PLAN CHECKING fEE � � - -
lender's Name � . , . �
- , - P€RMFF-�SSUIPJGF€E.. .. . . ,
lendei s Addresa - �� .
I certity thai I have read this application and state ihat tMe -� �TQFAL FEE.. .
abova inf�matio�.is corrsct.I agree to comply with ap Counry . j
ordirwnces and Sfote laws regufati�g Electrical wiring,and ...... . f
hereby outhorize representutives of 1his�County to enter apon � � _. -- i
the bove-mentioned prvperty for inspectioqpurposes. �
C'� L/������ SEE REYERSE PQR EXPLANATORY LANGURGE
Sigaatore of Perp�ttee Date - - -
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