HomeMy WebLinkAbout1649A (9) �. WORKERS'COMPENSATION DECIARAT�ON 76A663 10/81 pp T1 �{ F (�� �`Qi T �
. � here6y aff�rm thai 1 haYs.a cerri4fcate of conseof to self �"�G �• • ����••O•� • o� ����•�'v^" ����• � �
insure,or o certifiwte of Workers'Compensation Insurance, COIJNTY OF LOS ANGELES BUIIDING AND SAFETY
o+a certifiecf'copy tFarev#(Sec 3SW,Eab.C.) - � -
Q cy N . cam��y:_�pg,� we�rruenrrr�o H�t� a�ooRess 835 �
rtif'�ed copy�is hereby turnished. � -New Residential Bldgs. � EACH NO. _ _ FEE _. .._.. ..
- Lertified copy is�filed with the county building Inspec 1&2Family,Sq.kF��.r�— f — ; LOGSI� �
tion department . Moki-famify Sq.R. — ���ST � �T r'
� �� p Residentiat Swimmirtg Pools �RO55 ST.- !V
. Date a-9?—R4 Applicartt �--T.. Mr('-aa_.Fl rr�Fri . OwNER QR.. � .
- � FIRM tJAME --
� CER7IFICATE dF€XEMPi1QN FROM WORKERS'� � �MA t � - � -
Outlets:Rec_tiqht_Sw._
� - COMPENSAHQN tNSURANCE- � � ADDRE55
First 20
(Thf=�esNon e�ed notlk tonplQted if tbw wotk Gtroiv�d hy yotal No. Additionai CIiY T .
. . tFe�parmit is fw aw huadrod dollan(StOpy or feu:)- ptqN CtiEC�c... - _ —
, (certify.tFwt in Me pertarmance of.the work.for which this - � qpp��.p�----� --
; permN is issved,-1 shokl not empfoy any person irt any�manner � . .- . . .. _.
- saas ta become subject to the Warkers'Compensation laws. lighting Fixtures First 20� . ADDRESS �
� � . .. � � Total No. Additionol .
CITY 7e1.No.
� E}ate 4pplicant � Fi.ed Appiiances Not Over i HP pERµR � �
NQTICE TQ APPLICA[�iT: !f, ofter making this Certifimfe of - APP[ICAM �� °
€xemption, you sho�4d�become subject fo rhe.Workers' Range_Heater�D_W.—
� Compeneation pravisions of the�taharEode,-you must�farth- - Oven _Dryer _W.M.— - - A6DRESS �
with compfy with such provisions or this permit shall be Top _FAU �—W.H.—
deemedrevoked. . . . �-� � . � � � GFY-- ieL No.
- Hood _fan ,.,,_,Other— � �
_ - �� lfCEfJSED CONTRACTORS DECLARATION Disp. _Room Air Cond. — ��N�� Ct
-I hereby uEfirm thot i�am licena�-under-pFogisicros o€-€#wpter4 - REG.NEtMBER
� (commeneing-�weth uectiare 7000}-0#Uivison-3�{--tha:&ueness � - DISTBICT WO. . PRQCESSED BY !
. Power Appar€rtus&Lorga Applionces
.and.Prn#essions Code,nnd my license en irt fvif force and ef£ect. . ��( . �Y �
- - �- Size&Type HP,KW,KVA,or KVAR� - u �
�_ ticense Number Q�Q�4� Lic.Clac�'�� . � Up to}Ind. F4NAt � , t?
Over 7 to IO lnd. � - DA� �� �� �� YALI6ATN}N . �
Cor�tractor jy},P�j,(`�,� Date 7—�Z—$� Over 10 to 50 Incl. , �- �
. Q � - FENA . . V
I am axempt under Sec.- Over 50 fo t00 Inc. BY �
a
- O^ier 100 y�
B.&P.C.for this reason � � � Z
. . ��e � - Services;Swbd.,MCC 8 Panelboards
_ � 0-200 Amp.Under 600 V �
Signature � - - -'�-�2(Yl��-1000 Amp:Under�600 V - � . . .
❑ � . . - Over 1000 Amp.or Over h�Q V - � - � .
Exemption for Reg.Maini.Ekect. �.�6�Q p
� SINGLE FAMIIY Temp.Pflwer Pole 8 Appvr�enances �
HOME OWNER-BUIIDER DECLARATION - �- � . � $�r � . . •`L-
� Sign w�Eh One Bra�ch Circuif - .
� 1 hereby affirm thot 1 am exemp£from Fhe Contraczor's Lkense qdditional Sign Branch Clrcuits
� Law for the followrng reoson(Section 703k.5, Business and� - :E •� 0�Jr Q
Professions Code): � - - � -
�. � � Misc.Conduits 8 Conduttors •,� � Cl��'+J�t}�
i,as owner ot the property,wilf da the work arid the
. shucture is not intended or offered for saie (Settio� . �her(See Complete Fee ScheduleJ_ � Q 7,�G����5
7Q44,8usiness and Professions Cade). �
CONSTRUCTION tENDWG AGENCY � � - , �
- !hereby affirm that there is a consfrudion Iending agency for - �
-� the perfn.mo�ce of the work for which this permit is�ssued PERMIT FEE (S�b-Total) .
{Sec.3047,Civ.C.). . . . .
- - PLAN CHECKING FEE -
' lender's Name �
� - � ... PERMfT ISSUfNG FEE -
'. lender's Addreu � . �
� , i certify that I have read this appticotion ond state thoi the F�TAL FEE- � �
, above information is mnect.I agree to mmply wi�h all County � .
ordin6nces and State lows regolating Eledricol wiring,and . �
- hereby authorize represeroatives of thisLovnry-to er+�er upon - � . -
the�ent��per for insPection purposes. � � . .
r c-�� p�-- SEE BEYERSE FOR EXPLANATORY LANGUAGE
7"�!Y�(1_l
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