HomeMy WebLinkAbout1695A WORKERS COMPENSATIONDECLARATION - ���- �Q�e� - �, p►p��CATIQ�D-�IFf)R�-�LECTRiCAL- PERMIT � � �.
. 1 here6y nf'�m that I have o certificate of consent.#o.setf �'� � � '�.
insure,or aE mfgnte of Workers'Campensation Insuronce, C011MTY OF LO$ANGELES BUILDfNG AND SAFETY
- or c5 e u t6 reo£�$e c.3606 C-�.t. � . �
PoliCy��Company ... ._ . � ,. .. . fOR APPIICAMT TO Fltl IFF ._--. �� �,,I
. �� Ceriified copy�is hereby furnished:- New Residential 6lcfgs.&P I ��H No. FEE AO�RESS - �
� � t&2-Famil -Ft.�Q_ _ — ; L��A�� �
-C'erliiied copy is filed-with the county bu�(clmg inspec- Y�59�
- f� tion departmens. .... " - ,_.- -.-� . �_.Multi-family Sq__E� — �NEAREST _. . _._ .
__ . ___.._ _ -...__.. _ . _.
.. �- CROSS 5T. _- _�'f'_.
potg� �����w-�Q�'' ,,�o�� -�Reaidantiol Swimming Pools OWNER OR '� �
, -��Si-AgP _�___. __. .
. .. FIRM NAME
-�- -CERFIFfCATE Of EXEMPTION-FROM WORKERS'-�- ��MAf[ �
. - - CAM�NSRTIdN�{NSklR,4NCE�. . . Outlef5:Rec_Light_Sw._ ADDRE55 '
TIiIf iYiN6R lIYYd il�'��.00111 N tMe-wark imofved b � First 2(1
. � � P�°d Y ' iotal No. Additional CITY gi�� �.- rei.No. gZg-967— 4I
_ tha pormit is fw ana kundnd dolkro{=106)ar bss.) �- � ���K .
t tenify that in tkeparfarmance of the woik for wfiich this . � - qppE��r��� � � -
- permif is issued,t shall not emptoy any persqn In any martner � � . -
, so cs to-become su6ject 3n the Workers'Compensation taws. �gMting Hxtures Pirst 20 ADDRESS
� � . . . - .� : � . Totel No. �Additianal - CITY Tel.No.
Date Appliarnt � Fixed Appliances M1Fot Over t HP PERM47 - - �
NOTIC€ f0 AP�[IGRNT: If, after making fhi5 Certificote of A���y�� t� N
� Exemption, yau� 3houtc# become subjeU to tFe�Workers' .Range_Heater_D.W.— . .
_- Compenwtion provisions vi ihe tabar Code,you must€or�h- Oven _Dryer —W.M._ � AQQRESS P�O. � 1 ��
with. camply with sucfi provfsions or fhis parmit shall be Top —PAU —W.H.— .
- deemed rewksd. - . - - Mood —Fon _Qlher— CfTY � Tei.M1io: _
. IiCENSED C6NTRACTORS QECtARATlOFV . � • •
�. I hereby offirm ifiai I am(4censed under pravisions of Chopter 9 Qisp. _.._Room Air Cond. — RE�GNN MBER � ����0�•� —
(commencing wfth Sectiert7000}o{€tivision-3 of the Business - � DtSFRICT NO. PROCESSEO BY
� . and Proftssiona Code,-and my ticense-is in fWli farce.and effect. Power Apparatus&Large Applictnces I� . �
�/' Size 6 Type HP,KW,KVA,or KVAR� � . p
. Cicense Num6er_E�S�l����c,flas¢��- �� Up ro 1 4nd. . FFNAL V
�L.C�I�M 7��C,},� Over T to IO lrtct. DATf l,"� Z,3.y...=r""":. YALF6ATfON �
Conuacror - Date Over 70 to 50 Ind. � -�
FINAL ~
� � I am exempt under Sec � Over 5670 100 Inc _ BY �.._.� . a
� B.BP.C.for this reason - �ef�� Z
� - Date: - . �vices<Swbd.,MCC&Panelb�rds � . . . -
,, _ - � - . . � 0-2C10 Amp.Under 600 V - -
� Signafure 2(11-1U�0 Amp.Under 500 V .
� � . � Over lOpQ Amp.or Over 600 V
Exemp�ion{�Reg.Moint.Elxf. z� b Q.�{�
� SINGtE PAMIlY � Temp.Pawer Pote 8 App�rrenances�
' HOME OWNER-BUtLDER DECtARATION " �� � ° � °1
� i hereby affirm that I am exempt from the Conhactor's License Sign with One Bronch Circu'�t . �
low for the fotlowing reason(Section 7031.5, Business ond ���t�oan!Sig�&anch Circoits - f�•.e�E,� C
- Prefessions Gode): - - .. _
�� - �� Misc Gonduifs 8 ConduUors. •° ���� G"
1,as owner of the property,will do the work and the�� .
. stfyctt�re is net�intended ar nffered for.suie(Sec�ion --- Other(See Complete Fee Schedule)_ _ � _ O�.Z�J`'t�i b �
�� 7044,Business and Professians Code).
CONSTRUCTION LEN6tNG AGENCY . . - . . �
I hereby offirm that Ihere is a consiruction tending agency for . ,
� theperformunce o4 the wark�for which this permit is issued - pERM�T FEE . (Sub-Total) � . - ..
: � (Sec.3097,Civ.C.�. . .
' - - - � � PLAN CHECKING fEE- - - . . .
Lende�s Name � � i/�
� . . PERM4T-ISSUWG FEE /(� -
lender's Addrass -- - � � r� t�
� 1 cerlify thot�f have read this application and stafe that�he � TQT�.� � l�� ��J - � �
above informntion is wrrect.I agree to comply wifh a!f County -
ordinonces ond Stute laws regulating Electriwl wiring,and . � _ �
hereby authorize representotives of this Counly to enter upon - ' �
the-above-mentinned-{sroperiy for-inspection pwposes. - � -
��� �y'�����'�S SEE REVERSEFORfXPLANATGRY LANGUAGE
��
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Signature of Permittee Dore . � .
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