HomeMy WebLinkAbout1697A WORKERS'COMPENSATION DECLARATlON �6Ad63 �Q�B� APPf.iCATtOId FOR ELECTRICA! PERMIT - � I
I hereby affirm that 1 have a certifimte of tonseni to self CE-805G
�nsure,or a certificate of Workers'Compensotion Insorance, COUNTY aF LOS ANGELES BUILDING AND SAFETY
or a certified-copy ihereof(Sec.3800,Lab.C.) �
��. P�olicy No.f'7`>'T-r n�+rK'pmpany IN� FOR APPtiCANT FG Fltt IN- � � JOB 84 . �
Ce�+ified co�py is hevreby fumished. New Residential Bldgs.,&�P�qqf� - �CH Na. ({� RDDRE55
� i s z-Fom�i Ff.1Y�v s = s iocnuTr TR 35581 Dia�mnd Bar
,Certified copy is filed with ihe cnunty building inspeo- Y•$4�
tioo depahment - Multi-family Sq.ft. NE4RE5T /�� /
CROS5 5T. G�[lT [p
� w Residential Swimming Poo4s OWNER OR
Dnte���S3�i Applimnt� �m'�(E.+ �ECty''C
� - FIRM NAME
� -CERTtfiCATE OP EXEMPTION FROM WORKERS' � Oullets:Rec_Light_Sw.� qpp�RESS 1Q�]Q PctT']t
- CQMPENSATIQN INSURANCE � `
Th{a saetian need�rot b�cwn ted iF the waric inwf�ed b � First 20
� � 7 Fo1a1 No. CITY • . Tet_No
�. the pormff is fvr o1n hundrad doNors(5100)�or Isss.} . Additianol ... . — _ — 1
I certify t6ot irt�he per€wmvoce of�the work`for wFitF this _ - � - q�N��� �
� perm{t is issued,t shali noi employ any person in any manner � �
so.as to become sobject to the Workers'Compensation Laws. - Lighting�Fixt�res Firsf 20 AD6RE55
� � Totol Na. Additiona!�_ . . .
�ate �.r licant - . QTY Tel.No. -
P -.. � .. - Fixed Appliantes Nof Over i HP . pEgµR
NOTICE f0 APPtICdNT:-tf-, after moking-th'rs Eerttficate-of� - A�t�caM�� ��
- Exemptioq yQc� sheuld become subjecf to the Workers' Ronge_Heater_D.W._
Eompensotian-provisians-ef iheka�osL-0cte,�oa-musk#cuth-._ . Qren i Qryer�_W.M._ AD6RESS � .
-wiih comply with-such�proviseons o:-+hes permit shnkl 6e Top _FAt! —W.H.— . � .
� � deemed-re�oked: ..._.- .-... . .. .. . . CITY • TeL No.
LFCENSE6 CONTRAETOR513ECtABA7lOM. Hood _Pan _Orher_ �`t1Y10 �
� Disp. _Roam Rir Cond. — l��� . Cfass.
� 1 hereby affims that}artF lice�sed under provisions oE Chap�er 9 REG.NUMB€R — .. �
{commerxing with Sectian.10�1 of.4}i�ision 3 of the-Business Power Apparot�s 8 targe Apptionces DIST&FCT NO.�� PROCESSED BY } �
- and Pro€essions Lode,and-my kicense is in fu41{wce and ef4ect.� n, �
. �.- -- � - � Size&Type HP,KW,KVA,w KVAR . a �
- ticense fJumber 42Q7$g Eit.Class�'-i�� . . . � - � - FiNAL � �
- . �p fo 1 Ind.
� ,�EC.�ZG3�.. � . . 7—�{—�5 . Over_1 Yo 10 Incl. � pa�E-� ` ,� YAt{DATIOPI Q-
, Confracror €late Over I6 to 5(Y Ind. � � -
.. ❑ � . ftNAt - . �...
I am.exempr vnder Sec. Over 50 to tOQ Inc. 8Y � �
B.&P.C.for[his reason Over 100 N '
� . $ervices,Sw6d.,MCC B�Panel6oards � - . a i
- � Date: p_�y Amp.Under h00 V � -j
. - S�gnature 201-1000 Amp.Under 600 V - - .
-. � ... _ .Over 1000 Amp,ar Over 60Q V . . .„zp� �Q.�hy
Exempfion for Reg.Maint.Elect. - - �
SINGLE FAAAIIY iemp:Povrer Pole&Appurienances . �`}) • • • •2
-- HOME OWNER-BUfLDER DECLARATION Sign wiFh One&ancb Circoit
� !hefeby affirm that f om exempt from the Contractor's License �AdditiQnol Sign Branch Circuits . � •-�6�� Q
law fw the foflowing reason(Sedion 7037.5, Business and -
. PFofessions Code}: . - - • • ��t�.1 (,'u
❑ 1,as owner of the property,will do ihe work and�he �Misc.Conduits 8 Condoctors ' � �
- strutture is not intended or offered for saie(Section -� Other(See Complete Pee ScheduleJ_.. � - �Z 2 S`�}��
. 7644,Business and Professions Code). �
- CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a con5kuction lending ogenty for . . -
the performonce of the work for which this permit is_issued� PERMfT PEE (Sub-Total} .
(Sec.3097;Civ.f.}. .
� - PLAN CHECKING FEE . -
� Lendei s Name � .
. � PERMlT ISSUWG FEE . .
Lender's Address � � . �
�� I cerTify�hot i have reud this application and state thnt the TQTAL FEE . � � �
above in#ormution is correct.1 agree to compiy with otl County -
�� ordi�ances and State laws regulating Electrical wiring,and . � � ,
hereby outhorize represeMafives of this County to enter upon � � --
the abave-mentionad praperty for inspection purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE
��-1�'� ���-ia�J.t_.�7-22-85
Signamre of Perm�ttee Date . � . � ,!
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