HomeMy WebLinkAbout1675A WORKERS'COMPENSATION bECLARAiION � ��� ���81 ,qpRL1E�Tlt31'!-EOR- ELECTPiCAL PERMIT - . � �
. I hereby affirm thot I bove a cerlificate of consent to self �'� t -
insure,or a tertificate of Workers'Campensation�nwrance, COUNTY OF LOS ANGELES BUILDING AND SAPETY
or a certified'copy thereof(Sec.38Q0,Lab.C.J , � �
- Policy No.C_?�7 i a(1F'iO'em��y �`� fOR APPtICANT IO NLL.IN - ADORE55
�� Certified copy is.hereby furnished. New Residential Bldg�j ools �� �� - FEE
:Certified copy is filed wlth the tounty buNding inspec- 1 8 2-fomily,Sq.Ff?���� $ � Q4. — t� ��E�TY '� . •
�'"� tian deportment. Multi-fnmily Sq.Ft. — �NEARESF. - ..
- Residenfiat Swimmin Pools CROSS 5T.
, Date�: 7—?9—S�tS Applicans��'1'�F MnC'aa Fl cni-ri n� 9 OWNER OR �
FIRM NAME
_ �CERTkFICA7E OF EXEMPIION�FROM YiIORKERS' Outlets:Kec_Cight_Sw._ --- ''Ma`« �
COMPENSATION INSUR.4NCE p,ppgE�,S
� (Thia��etion nwd erot ha camplefed if Nrs work Fmotred 6y F��st 20
fhe.permtt is for ona hundrvd dollan(5700)or Ieu.) Total No. Addifional� ��T� ' Tel.-No � _ 1 ,
, 1 certify that in the performnnce of the work for which this �-- PEANCHECK �- � �I
. -permit is iss�ed,I sha!!not employ cny person in any manner APPCICANT �
sa as to become subject to the Workers'Compertsation Laws. Light'rng Fixtures First 2Q ADpR€$$ '
� Total No. Additiona!
CITY TeI:No.
� � �ate ApplicaN - Fixed Applionces Nof Over 1 HP
� � NOTICE TO APPLICANT: If,atter making this Certifimte of � � ffRM�T -
Exemption, you-shoukd become subject to fhe Workers' Range_Heater_D.W.— ����T�-�� ��` -_
��- Compensoiian provisions of fhe Labor Code,you must forih- Oven _Dryer —W.M..._ ADDRESS
: with comply with such provisions or Fhis permit shail be Top _fAU —W.H.— �
-� deemed revoked. � - - � - - Hood .._Fan _Other_ ��N� - TeL No. — 4 2
. � UCENSED CONTRACTpRS.DEC[ARATIQN •
� � - - Disp. _Room Rir Cond. _ ��E��
_� _ 1 hereby affkm that I nm licensed under provisians o4 Chapter 4 � . REG.NUMBER Class.
(commencing with Section 76W)of n'rvision 3 af ihe Business Power Apporotus&Lrnge Appiiances � - �Q�T�CT�� PROCESSED BY�� }
and Vrofessions Code,ond my Iicertse ts in fuli force and effect. } „ � �
.. .. . - � Size 8 Fype HP.KW,KVA,ar KVAR . ��a
license Number 42(}7a8 Lic.Ctau �`--1(] �
. . Up to 7 IncL � flNAL �1 U
� - Qver 1 to}O Irtd.. DATE L yfi �
. -Contractor �.1'�`�'i"�"�C-B�- Date 7-2?—$� 6ver i0 ro 50 Ind. .- .. .. ' t Y DATIQN._ �
� - . FlNAL � . _ �
l nm exempf under Sec. Over 50 Fo F00 Inc .gy. yi
. � B.BP.C.foi this reason Over 100 � � �
Services,Sw6d.,MGC&Panelboards � - - a
� 6ater p-��,p Amp,Under 600 V . -
Sig�awre 2ot-t000 Amp.Under 600 v ��b Z 5 A
Over 1000 Amp,or Qyer 600 V
Q Exemption for Reg.Maint.Etett. - . � . fr� � • r s�
.... SiNGLE FAMIIY Temp.Power Pole&Appurtenaaces � .
� HOME QWNER-BUILDER DECIARATION � - ��•���.5 O -
Sign wifh One Branch Circuit -
- I hereby affirm that f am exempt from the Controttor's License
-� Law for tha tot[owing recison(Sectiort 7631.5,8us�ness ar�d �'�i°^0��5�9n Branch-Circuits - . . � .�• • •�1.rj!]�
� Prufeuions Code): ' � - � � 0�,L 5�$5
❑ I,ns owner of the property,will do tbe work and ihe Misc.Conduirs 8 Conducfors � -
- structure is not intended or offered for sale(Section Other(See Complete fee Schedule}_ - � �
� 76d4,8usiness ond Professions Code}. - � �
- CONSTRUCTION LEND4NG AGENCY -
1 hereby affirm ihaf fhere is a mnstroction Iending age�cy for �
. the performance of fhe woric for which ihis permit is issued pERMIT FEE � � (Su6-Total) - - - . . --..
(Sec.3Q97,Civ.C.J. .
� � � - - - -PIAN CHECKING FEE � , --
Lender's Name -
- � � - PfRM1F ISSk1fNG FEE � - .. 1Q �ja . ._ .
- lender's Address . �
� I cerlify that i have read this applimtion and s�ote ihat ihe TQTAL FEE 8��c,Q� , .
above information is correct.i ogree to comply with all County . � �--
' ordinances and Sta�e laws regulating Electrical wiring,and -
hereby nuthorire represenmfives of ihis County to enier upon � - � , � -- -� - - ---�
t6e a ve-menfi,o��e/d propeny for inspection porposes. $�E REVERSE POR EXPLANATORY IANGUAGE
��I�"'• /l/(�"� / �' O( �O�
Signature of Permittee 6ote . - - i
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