HomeMy WebLinkAbout1678A WORKERS'COMPENSATION DKtARATtON ��� ���81 qpp�,���T14N .F4L4 ElECTE�IC��. PERMIT � �
i hereby affirm that i hove a cer�i#icate of consent to self �'�
insure,or n certifimte of Workers Compensation Insurance, COUNTY C?F COS ANGEIES BU{IDING AND SAPETY
or a certifi d capy lhereof(Sec 3800,lpb.C.� .
PolicY tJj,��,��Z��:,���"�ompany,�i/J� � FOR APPIiCANT TQ f�LLL Hf .. - . - J08 - . .
Certified copy.is hereby forn�shed._ _ . ._. New Residentiat Bfdgs. �k� NO. -{�E ADORE55
Gertiffed copy is filed with the munty burlding inspec- -1 8 2-Family,Sq.Ft.-� � � — $ L�CAItTY
� - -�tion departmenL ��� � ,.y�/�/ Multi-famrly Sq.Ft.. — NEAREST � � D
��� PP ��!//L C7�. Residentin4 Swimming Pools � CR65S ST.
Date A licnnt QWNER OR �
FIRM NAME
� . CERTIFtCATE OF EXEMPFION FROM WORK€RS' - � putlets:Rec_Light_Sw._ ` �� ' �
� - - COMPENSATkON fNSURAtdCE ppRE55
(ihls�oclba t�ead not 6n ewnplN�i�tha-wark invotred � Fint 2Q -
. . tl�a porenif is for�ona hurtdrod dollars{S1MFj or loss.}- � Total No. Additional�- '- G� D' te�.No _ _ 1
. � -!cerfify that'rn the performan¢e ofihe�wartciorwhicfi thls � . � , '.. :. �N��-.... ...- . . .
- permif is issued,I shall vat employ.any person in any manner - p�'�'�
so as to become subjecs fo�the Workers'�Compensotioniowa Lighting Pixr�res Eirst 20 ADpRESS �
Total No. Additionol CITY
Date °PPlicanF. � Tel.No.
� � NOTICE TO-APPLICANT: If,�aHei making this Certificate of Fixed Appliances Not Over 1 HP . p�R,� •-
Exemprion, you should.�come subject--to-the�Warkers' _ Ronge_Heater_D.W._ qpp��qN7 F� �r ,
� Compensatioe provieio�s of-the La6or Gode;yQd musrforth- Oven _Qryer :._W.M._ RDDRESS - � - �
with rnmply-ivifh svch provisrorrs-w-�this permir sholt.be Fop _FAU _W.H.— � � _
�� � -deemed.reyoked.. .._ ._.�. _ _.__._.-. . . . CIiY • -Tel.MorJ_ .
� lICENSEQ CON7RAG7QR5 RECLARATION � Hood _Fan _Orher_ -
� Di _Room Air Cond. — t10EN5E OR. �
k he[eby qHirm.thaf 1 am licerued u�er provisia�s�af Ghapter 4 �" . . - - R€G.NUMBER Cktss_ _
� jmmmencingwifh Sert;an�7€l06}-oF[)ivisicin-3�#-the-8ttsirress� Power Apparatus&4orge�Applionces D45FR{CT NO. - PROCESSED-BY �
andProlessionsCade.-aridmy{icenseisinfukFfwc andeffect JQ � �
�,1 Siza 8 Tppe HP,KW,KVA,or KYAR - �� ( Q
- L"rcense Number -�Lic.Civss � !� . _._ .. Up fo f tnd. � FWAL .. _ . . V
��/C{�]�/A� ���, . Orer 1 ta 101ncf. � DA� '������ VkLIDATlQN . � #t
Co�irnctor ��,lJ�/L Daie p�g�70 to Sd Irxl. ��� � � (
�� I om exempf under Sec � Qver 50 to 1Q0 tnc -� 6y � W �
dver 7W
- 8.8P.C,for this reason _ � �
�nte: Services,Sw6d.;AM1CC&PPo�elboards � - � � �
� 0-20(}Amp.Ur�der 60f7 Y �
- Signature , 20)�-1000 Amp:Under 600 V �
❑ � . . . - Over it700 Amp.or Over 6pQ Y -
. Exemption for Reg.Mainr.Etect, . z� 6 7.�1�i
$INGLE FAMItY - Temp:-Power Pale 8 Appurtenances
HOME OWNER-BUILDER DECtAR.4TiON �e •.•�s •2
t hereby affirm that F am exempf from the Contractor`s license Sign with One 8ranch Circ�it .
� - law for the fo�lowinq reason(Section 7031.5,Business and Addifianai Sign Branch Circuits � . + a e�1 c Gi
Professions Code): � � � '
- � - Misc.Conduits B Conduciore � •�� •�1.�t c=.�
, I,as owner of the property,wil!do the work and!he
� - structure is not ivtended or offered for saie (Sec�ion Other(See Complete Fee Schedule)_ � - � S
' -7044,Business ond Professions Code). � Q-7 2�-�v ,
� - � CONSiRUGT10N LEN�ING AGENCY � �
� !here6y affirm rhat�here is a construction tending agenty for .
' ihe performance ofi the work for which ihis permit is issued �� p�MIT FEE (Su6-Tota!) -
� (Set.3Q97,Civ.C.}. . . . . . -
� � � PtAN CHECKING F€E - � - � -
; lander`s Name - A - .
. - PERMFT f55tjING FEE � U �
� tender's Address �
. I certify tbot I have read this appiicarion ond state that!he - - TOFAL FEE - � � �
above infwmation is mrrect.1 agree to comply wifh all County . --�--
ordinances ond State lows regulating Eledriml wiring,�ond _ � � �
herehy authorize repre:eniatires of thisCavnty ta emec upon - � � � �-
the a ve-mentioned properry for inspectioR purposes: SEE REVERSE fQR EXPLANATORY lANGUAGE
��� � ���-��
. Signature of Permiuee Date _ � - � � +
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