No preview available
HomeMy WebLinkAbout1694A (10) 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 : - - - . � h [ ' 17 'D . u �y O O�b � . . . . ... . . . �"�"i '�„ � a�3�.' ° L a�.'`a a � c.'," m = e.°ic > �o'�._o N n o �4�� a � � o o m aa o D 6r. E.bv � c. � s.c o Uaoh � c,} .. � � c-m o c o��,-D o " m 3 m t oro v m�'�^ -_ V o o �rnTn o a c c.^..,w � ar' m.c° E� o =o � Z u a� � � a a o E •, E o�� o � b 3 ; � ` u Q N � s�a ay m ao c�o�.°c �°.°v ov o ;o a.o �.Q -E c '�'� �.."�`�� O 0 a '� �'Ot�1 V O a a� O � �v�i , ' - .... °C ° ni.�� .:.o°�c0 n � Eo 3 mc « e� ° i.m g �- o � � _ � m� �.. r�o , o�smb �- � E� a °� 000�. °a`ta£ aoyam �= o.'Qct' , p � rnu . � a�soE ° ° ° ", a� mcm � J e x �� � o � ` � � o a� �.. � � °v--� a' °'3p C N o--- � L ��° ° >'v � 3>'.c- v°'i�.,' D , � � �••�- p O � p 03 w b �y t3� O C � m �'p"p.C,> � � . � � �. , � Cp 6 �„��"�C 0 �0"Qs O� C . O nb �b m N� O � a . � . _ a� .,C� ..b-�... b ti �,',�y 4 2 C C G ; .y+m. � ; � � L . . . �: o � '°'�E°� �>,y '' o " �-b' c_c �,`�a � �- o _, E�..d ��>,o°'.o °� �ug " m°° N „ � o v= o `� `F �p� � �° c.o a.��g o ° ,n ° Y ��o £ � �-o x ., . °° � M`_ °�'� ° m'O a�` `��,'a.�a Da� ro � d � � � roo � a«'� flo„'c�"• a�auNo''` `mi=�, E ,o a 3 c — c �so ; o ., a m � O sv ] 6�� � OU °o� ub ��° ; ; � EOC � _�m ,, o a�Eva ru a Q Z C1 N ti Yq. i Q � � O � � � � W � � � D W W � � Y � ~ O > R o Q o z ` . � 3 Z � o g a N � o a a �" x Z a � � �n r � W Z O � � O � u. z � � �