HomeMy WebLinkAbout1694A WORKER$'COMPENSATION DECtARAAON - �bA663 �o�e� APPtKQ►TtQL� FQR ELECTRIC�AL PlERMIT �
i hereby offirm that I Fwve a certificate af consent ro self �-g�
insure,or o-certif�cate of-YUorkers`C.ompensation lnsu�ance, CQUNTY OF tOS ANGELES BUtIDING AND SAfETY
- or'a :{q�,y�- her f�(Set.360D,tob.C.} . ..
Pao��F_•�Eom(wnysj•,,.�� ... . FOIt AMIICANT SO R�C W - J06 ��
.-CeAified mpy is here6y furnished. _ New Residentiol Bidgs. P�Z� � �N NO- FEE ADDRE55 9p2 ' Glass Drive
�
C'�ertified copy�s filed with tfie cooMy buikding inspeo- t&2-Pamily,Sy.Ft. � — S LOCALITY � '
� — �t�AREST , y pr
-Nort epurfinent -...-� -�. -. .. ... . Muiti-fomitySq.R:- . � �gp�,SST. L�C� O
pa� ? i��iT �f�� ResidentioY Sw4mming PoalS OWNER€�t - �
iFt���RP�. . . FfRM NAME.
� ' -CERTIFICATE OF EXEMPT(ON FROM WpRKERS' OuHets:Rec�_Light�5w._ V1E.'SV Dr ZQI
- � � COMPENSATION INSFIRANCE - � - - �AD6RES4-
.. {Thls��ction poed e�at be ccmpl�twLlf.dw wosk inroliwd 6y First 20 . .
tiw pormN is far ono#wndrod doUan{i106}-ar{ess.f... ioml No. Additionol �TY ' - Tel.No. - 41
F cettify that�in the performance of the work for which this � P���� �
.' permit is-iss�ad�,-t shafE not emptoy-ony person in uny maaner - �'�a�
- so as-ta�come su6ject to the 1Atodcers'Compensotiort luws. fighting Fixivres First 20 ADDRE55 �
. . .. . � � - �- � ---- Totot No. additional - .
Pate opplimnf - - �- � etTY Tai.No.
�ixed Apptiances Not Over F HP p€�4T
NOTICf T6 APPLICAFtT:-If,after�makirtg this Certificate of qppL1UNT- �� ��
� Exemption, yo� sho�ld�becart�e-�subject-Jo ehe Wor4ers' Rqnge—Heater_D.W.— - .T � ���T�.'
Gompertsafion provisions o#the Lv6ar Code;.}�v mvst�forth- Oven _Dry�r _W.M._ AD6RE5$^ � -
. with comp4y wtth such�Fuovisiorts or tMis permit shall be Top ..�FAU .—W.H.— P`a` � �'1"3'3' —
deerried�reroked:--� -� � �� . - - EkTY Fef.No
tICENSED CQNTRACTORS DECtARATION �� —Pon _pthcr_
� khersbyaffirmlhetlamlicensedundeepmrisionsof-Chnpter4 �� Disp. __._RoomAirCond. _ RE�G�N�t�MBER Class
� 61STR�CT NO. PR $�D&Y �.
(commenu+g wftFr 5ection 76�f of Dixisian 3 cs€-the-$useness Power Apparotus&Large Appliances
.. .and Prafesa+ens C�e,arad�my kicense-isi��€u}L#wce and eHect. � . . .�h � �
�- y/r � Size 8 Fype HP,KW,KYA,or KVAR �N - �
. license Num6er�,ry�('3.���ic Class.� .. Up to 1 Ind. PCNAL V
���1�'��l ' ��p�' -- Over 1 fo}O lncl. �� �,1;m�,� � YALiDATION � �
ConiraUor� �ate-7�' ��1 O
Over 1Q to 5�Ind. � I-
.. ❑ I am exempt u�er Sec. . Over 50 to 100 Inc. gY At V �
� Over t00 �..---,..�.___`.-_.. . W
- B.&P.C.for this reoson ��n
. ..... - . . - �Ser�ices,Sw6d..MCC&Panelboards � . .. , Z
: . � . Date: . 6-1W Amp.Under 6W Y . . . . �. _
. Signpture - ZOt-1000 Amp.Under 6W V - �1 �9.�L A -
.. ❑ . . Over IOQQ Amp.or Qver 6pp V � � .
€zempttan for Reg.Maint Elecf. i�• • • • •�
, . - SWGtE FAMltY � Temp.Power Po}e&Appunenances � + • •(j� '� 0
- - HOME OWNER-BUILDER DECLARATION � �--� �
Sign wifh Qne 8ro�ch Circuit�
�� F hcreby affirm that!om exempt from ihe Comractor's Licerrse - - s � ��C� O` -
- Lnw for ihe fo44owing reoson(Seciion 703i.5, Business and ��tiona!Sign 8ra�cb Circvits -
Rrofe55ions Cade�: . _ C 7.rZ�_�v
� ❑ t,us owner of the property,will do the work and the Misc.-Condoits&Corduvors - . � - - -
. structure is aot intended or offered for sale (Section � 6fher(See Compiete Fee Schedule}_ � - �
. 7044,Business and Professions Cede). �
� � CONSTRUCTION LEN�fNG AGENCY -� . .
� I hereby affirm ihat there is a construction lending agency for � �
ihe parformonce of the work for which this permii is issued PERMIT FEE - (5�6-Tatal) �� � . �
.. (Sea3Q47;-Civ..C.)_- . . . .
��; � PLAN CHECKING FEE . - � -
'' Leode(s Name � �
. - PERMIT ISSUING FEE � fQ S� .
Lender's Address � . � .....
� �cerfify that f have read�his applicotion ond state that fhe TOTAI FEE � - �D . -
' above information is correct.I ogree to compfy with all Counry � . . ...
ordinnnces ond State laws regulating flectricol wlring,and . - � .
'' hereby outharize reprasentatives of this County to enter upon _ � � . � ' � - . --- -----_ -_.-_..
the ubove-menYoned property{or inspection purposes_ S�REVERSE FOR EXPIANATORY IANGUAGE
�en�aP 7YJ` - -
�� Signature of Permittee - � Ome : - - - . �
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