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HomeMy WebLinkAbout1676A (10) i WORKERS'COMPENSATION DECL4RATION �da� �Q�81 qPPlICATtON FOR ELECTRICA! PE�iMIT � � ' t hereby affirm thot{hove.a certificote of mnsent.ro self. �'� . �nsore,or a certificate of Workers Compensation lnsurance, COUNTY OF L05 ANGELES BUILDING A�SAFE7Y �or'a c 'ied copy th_ er�of(Sec.3800,Cob.C� - . ,.a cy��J7tlLLS��com��y��?�..- . � FOR�rruunr To Fue a� � � �oa � Cerfified ca is here furniahed- �k . ryp. p� ADDRE55 _—! PY bY New Residentio!Bldgs.&Pools - �7 I 8&famil Ft. S — S LOCALITY - L}CI Gerti#ied topy is fifed with fhe courtty 6uifding inspeo- Y•59� 1�7.� 7C -fiort department.-� `���, Mviti-family Sq.Ft� — �RQ�S� ! G� � E3ate-�����Applicant .� J/Y�Pr���i Residenfial Swimming Pools QWNFRQR - �- � FIRM NAME � CERTIFICATE QF E%EMPFtON PROM WORKERS �MAi� � Outlets:Rec_Light_Sw._ � COMPENSATION ENSttRANCE -� � First 20 �D�� ���4 � (Thb s�ctlon naed�rot be cempleted if Nro woric inrohed by Tofal No. Additiana! CITY Ai��� ��. .Fel_t�o$1 - I � tl�Q pwmN is iw oew Mrndrad doflarr�S}ilfk}or fsas,} .. . , . I certify thot in the periprmunce of the work�for which(his ��-- - -� p�N�� € permit is issued,`i shatl not employ any person in pny manner L� hrin Fiztures First 2(} ADDRE55 � � so as to 6ecome sVbject tv the Workers'{ompensatimrfavn.� �J 9 - � �� .Total No. .��Rtianal - . _ CITY . Tel.No. Date �.^Y�cartt -- - �� - � Fized Appliances Not Over 1 HP PERMIF 3 NOTICE 1p�APPLICANT: �E,-after making rhis Certi/icate of . . �rrjsn � Exemplion, you shoufd become subject ro the�Workers' Ronge_Heater_6.W._ n�t�hli . _ ._ `-. � Compensarionprovisionsof-tlr�tabartode:.yw�-mcist'forth--. .-�-0ver*-_€3ryer-_W.M.�— - ADDRE55 . ,;, . �with comQly wi€h'..sucN provisit>na nr Yhie per�pit:shott be� .Top .,.+FAU —�W,H,—. .. . . .. . . .. .. _. deemed revoked.� -.�- - :. ......_. _ CiFY.. ..�.. Tel.No. - UCENSEQ G�PtiRACTORS DEEtARkTION Hood _Fan _Other_ . � GCENSE OR , .4hereby offkm ttwt f om ticensed u.+der provisions of Chapter 4 �'�- —Roam Air Cond. ., REG.NUMBER 2 d � CEass. _ � -(commencing with SectFon 760Q)of l3ivision 3 nf ihe 6usiness � pl$FRICT NQ. - PROCESSED BY - . -ot�dProfessiaasCode.flndmyliceas�isirt#ulF€arc arid.-e4#ect.� PowerApporatusBEargeAppliances � . ) . � 7 �-�f�� � _Size&Type HP,KW,KVA,or KVAR . . t� a :ticense Number-t��iC�E�tz_kic C�ms� . . Up fo 1 Incl. FINAL - � V � �(,�e/�/��Date���� dver i fo 1Q fncl. DATE �i- `���,� VALIDRflBN . Q Contractw Ovar 10 ta 50 Ind. - � ❑ FINAt I am exempY under Sec Qver 50 to 1Q6 4nc BY � 8.8P.C.for this reasan Over t00 _ � � . . . Daie: � Sarvices.Sw6d..MCC&Pansl6oards - .� - - . � - 0-200 Amp.Under 600 V � � � � .SigrroWre. . _._._� --.___ _.. _ � 2QT-1000 Amp.Undar 600 V � - - . - . � ❑ Over 1000 AmR.ar Over 600 V . ..... ._. .... .-:fxemptian-faef2eg-MnisL.flecP�--.�n ---' .-...._ -_ _ ..-.�._ __�.}-�-7.�..P, .._- ,. . , �. ... ... SINGL€-�FAMILY -��� - -:_ Temp.�Powerfote��&-Appurtenances �� _.� _ _ ..... --�' ,_. :�:�.�� a a_� _ - HOME OWPSER BUIt6€R DECtARAT10N � -. S�gR�ratf�.4ne 6ransh Cirsu"ri - - `" - _ �� 4 herebq aH�rm�thai I am ezemp�from�he Confractor's l�cense __:. ���+o���������iGEurts :: -:. ..:. �.:� -�-����Fm.� . �-� taw far the fasllowing.oeaspn..(Sectiou:761i_.5,.$usiaeu aud_ ...... _._ __. ." ': :. . ._ .. . . .:. _ . '.. RrafessionsCodej:. . .. .._ . . �:.-: _�...- -..- . -: �.: ���rj.(ii:_ .. . . . .. M�sc.Condvits R Lorrd+tctors . . .- . .: : _.�_e c ❑. 4,os owner of the praperpr,will.do the work and the �������pm �¢te Fee$chedvle _ .,__ . , � - � struclure.is not intende�or offeced 3or sate{Sectwn P � }— . . _.v_ . __� _ . ¢�s���,. . � 7064,Business and ProfesstnnaCodej. ... .. . - . �-- � ..-.... - . -: . , CQNSTRUC:TtQN tfFVDINC'r AG€NCY ` _ `-.: __ _ . _ . Ihereb�rc{fkm.ihWthers�isnconstructio�+{e�x3ingagencyfnc . -- -- .--_ - - �-��. -__- -.�..�. ..:- . _��_ . --_. . -- _ . .. _ ... the performance of t6e�work tar which this permif is issoed. PERMIT FEE � - _;,,;, __�_,(Sub.Totpt)-, -��� , . � (Sac.304T.Civ.�C,). ._.. _,_ _.. .__. _,_ _.._.� ._ __ _ .�.. . _. _-:,. _.. . _ : : . . .;-_ _:... � PEp[Id'�'IELYfN4G'fEf-- "-'-:- ' ,.._ '_'- ' .�- . . __: �..- - --_ -� - � Lender's Name .. -- '. " `.-- q -- -.. .. ..-. .�.. - _ PERMIf iSSi!!N�fFE _- a� -- -,- , Lender's Address � . . , .. _ -... . . . .. �t certify that f haYe reod this-opplication ond.stote that the : - TOTALFEE :-. .- -. . � 8 t� -:". ._....: . -'-.- -..-' ...... oboveinformaiioniscorrec):f�ngreeto�.�omptywitk-.at(County-�- - .--. ----- --.--..- ..-..--._ - . . . -. . .-.-�:-- - ordiriances and-51nte lqws_-regulating�,Etedricaf wiring,ond-�� .` . . . . ' . ... . . .. . .. . .�.� . � .. � herebyaulhorizecepratentativesvftbisCounk.fo.enterupon ... -. . . � ..-.. - .----. ..--- -- --_-.-.. .- . the 6ovo-men;ianed proper3y for enspecltoR pwpo;es. - _ ��� - _ SEE 8E1Ff85E E4R E�CRiAMAifl1EY�eurrier��_. _. � b`'�.�?-�s1���� __ _ __ _ � 5gnoture of Permittae -- - - �- pore:�' --- --.- - ._.-_ ---. -- . -. � � . . . . . :.. ,. �. . ... . , . . ._..__ ... . .. . . . . .. . . . .. . �.w..� _ � `��'I.�'-C Gi GI�� M y �►v � �+ �`y Q Q=� ` , . 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