HomeMy WebLinkAbout1665A WORKERS'COMPENSATlON DECLARATION ��� ���81 APPLICATIQN �QR� ELECTRICAL PERMIT �
1 hereby affirm that� hnve a certificate of consem to self �"a� � - -
insure,or a certificate of Workers'Compensotion Insurance, EQ(JNTY OE LOS ANGELES BUILD{NG AND SAFETY
ora ceriified copy thereof(Sec.3800,Lab.C.) -
...Policy No.C'7�77d(l�i(1"ompany � � FOR APFl1CANF f4 fNl IN - � JOB . _. _ � .
�.Lt erlified cupy is hereby£umished.� New Residential Bldgs: Is EACH M17C?. .�{- .. ADDRESS • •
Gertified topy is filed with the coonry building inspeo- 1&2-Family,Sq.F E — S .- � LOCAIIT .
_. .
1iQd�deportment. .. '� � - Multi-fami{y Sq.Ft. — � �+�� � .
� -� CRO55 57.
�� �� � Residentiai Swimm[ng Foots
� Dafe 7�77_—�ri. . Applicanl T NYY:�F. F:f.'HYr4�F2I . ORWMNF�R Q�R � � .
_ CERTIFICATE QF EXEMP710N FROM WORKERS' -p�f[eh:Rec`Light Sw._ � - -
, -�� ��- COMPENSATfO1V INSURANCE � F,rst p � q�ppRE55 �
(Thb sosfion need noT be complNod IE tho wor&invoirad by _7ota1 No. Addttiorw! C�TX Te
� the pareeA is for one hundied dolkrs(SiW�or fass.j — —
t certify ihat in the performance of the work for which this -� �`���E� � �
- permit is issued,I shall not employ any person in qny man�ar � APPUCc`NT-
so as to become subjed to the Workars'Compensation Laws. tighting Fixtures First 20 - A6DRESS -
- -�- � - . Total No. Addirionaf -
. � Dare nPPlimnt � - CfTY- Tel.No.
NQFICE TO APPttCliNF: If, a4ter making this Certificate of Fixed Appffantes No!Over t HP , pE� —•
...Ran e_Hearer_RW._ APPUCAnIT �� n .
ExempFiori, you should-6ecome--sdbject-to i6e Wo�kers' 9
-- CompensaFlon provisions af�the labor[ode;�yocr�musi forth- � Qven _Dryer _W.M.— ADDRESS a. $C�t IZli
- with tomply with�wch-proaisions-cu this pesmit skwii be Fop _FAU _W.M.— .
�. deemed-revoked.... - . � - .Naad .,,_fan _Other— C��Y� - � Tel.No. -
-LICENSEQ LONTRACTORS DKlARATlON _Raom Rir Eond. �����
�iherebyaff�rmthIN#amiieansedurtder-provisiotrs-a4€#rapter9 . ."Disp. — ttEG.��wutt�sEQ . Class.
. - (comrtrencengwifhSection�700f}f oFBivisiwr3�of-ifis-6usiness � _
� a�ProfeutansGaefe;orK#mylieetrseh�i»fiutt�Force�nd-eSfect. . Power./tpparatus-&Lorge.Appliances... . -. . _____ _ .. D45TRICTNO. � .. PROCESSEDBY �
. - � � Size 8 type NP,KW.KYA,or KYAR� . � - a
� Fice�se Number. d?(1'�dP. �Ic.Ciass�'—�E1 Up to 1 Incl. - FINAL - - U
.Qvet.Lio IO Lnci. DATf ..a � y�
FIPr�-r;r 7-22-85 L� - .�t�q.;=='� VALIDATION p
Controctor - - -Date
- ❑ - Over t6 to SQ IncL pINA! . . . �j
I am exempt under Sec. Over 50 to l00 Inc. BY W
-Ovar T00 ����-`
B.&P.C.fw this-reosoo- . "-.. �
- � 5ervices,Swtxd.,MCC�B Panelboards � � �
. t3ate: . p_ppp qmp.Under 600 Y
SignaWre 201-1000 Amp.Under 606 Y � - � - -
� � � Over 1Q00 Amp.or Over�OQ V - . .
Exemprion#or Reg.Mairtt€ted. �1 6!�5 A
SINGLE FAM4LY � temp:Vower Pote�&Appunenances #' �• •G
HOME OWNER-BUILDER DECLARATION - §�gn wtth One Bronch Circuit �- i
t hareby affirm ifiaf I am exempt from ihe Contracto�s Ckense - ,qdditional Sign Branck Eircuits-- �(�' �Q���
. 4aw for the following reason(Secfion 7631.5,Bu:inesa and . . � -
� (P'r�ofessions Code�: •�� � ().Fi.J Q u
� U i,as owrter of fhe property,will do the work and the - Misc Condaifs 8 Conductors � . - --
� strutture is not intended or offered for sa�le�Section ��her(See Compiefe Fee Schedule)_ , - Q�],_2;�$�j �
- 7Q44,Business and Professions Code}. � � - - -
� CONStRUCT10N LENDtNG AGENCY - -- - � _
- t hereby affirm that there is a co�strudion lending agenty for _ -
- - the performonce of the wwk for which ihis permi�is issoed pERMfF fEE�---�- � � � (Sub-Totot) . .
� (Sea 3097,Civ.C.). . . . . .
- - � � PLAN CHECK�NG FEE�- � � . . - _-- -._.. .
� Lender's Name � - - �- � �
PERMIT ISSU4NG P€E - - -
Eender's Address
i certify�hat 1 hove read this application and etate that the iOTAI,FEE.- S�
. abqve information is correcf.I agree to comply with alI Cauny � .
� ordinonces ond State lows regulating Elechiml wiring,and . ..__. � . - �
� hereby authorize representatives af�tfiis Counry to enter upo� � - � � - - �- �
��he bove-menrioned property for inspedion purposes. --SEE REVERSE FOR EXPLANATOR1l tANGUAGE
c-r..�-c����7 84���-- :
Signature of PermiNee Da�e . � .
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