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HomeMy WebLinkAbout1666A � - WORKERS'COMPENSATION DECLARATION �� ���81 APP11e�qTIQN �EOR ElECT.RlCAL PERMIT � i hereby aHirm that i hqve o certifieote-of-cansenf to self CEA(MG insure,or o cerfificate of Workers'Compensa�ion Inwrance, COUNTY OF LOS ANGELES BUIIDING AND SAFETY or a certified,copy the�eof(Sec.3800,Lab.C.) � - Policy �7 -G ny �]�A - .._. _ ... �--_..fQQMPII[AN7TQF1EE7ti- -__._____.___ -��.—__... _ ._ -.__._ - . � . ,�,� e .. . p) ....�mi5hed. .. -._. . New Residential&idgs. I �� NO. FEE ADDRESS • • _� ��ertlfied copy is filed with tbe county buNding 4nspec-- 1 8 2-Fam�ly,Sq.F������ s _ "` s tOCAfR • _ tior�depctrtmeM. _-_ ....-, .:�. ... Molfi-family Sq.-Ft. � -� - - NFAREST ._ _._-- � -- „ ��-- - Residential Swimming Pools �4�ST.- . oa�e�22-R� /+apucant m jyt'y�ar�rr*RrC awr�aoe . . fIRM F1AME � C€RTlFICATE OF EXEMPT16t�C-Fti6M W6RKERS'� ' Mkit�-� - ` - -�"��-��COMPEhiSATtON-tNSURANCf-�-���---� - - OuNets:RecAtight_Sw._ A�� . � ___- --_ ._ Pirst20 . (Thic axfiaq naQd nQt 4e eomplatod if iha wadc Invotvsd by... :7oral No. C4TV �... Tel - fbs permif Is for�om hundr�t_�ol�ars'(�}84j w Itss:j. . .. _ . Addltio�af . ..- ' � - F`certify that in ihe performonte of the��v+ork fib�whicK this� ��E,�qy� . ' parmit is i5sued,i sbal4�rsv�emptoy uny per�on irt artp rnanner- � � -- --- �-� . - -. . - --- ' __ -._-'- --_ - -- � so os to beceme avb{eck to:the.Wadcers':Co+npensati4t�ta.vts...:�_ iight�ng_€txt�rres :-.- F�[st.20 _.. .. -�. A��R€5�- -� '-� .. . - .. _ ,.. : � _ _.__ - -:�., _. . ._ ..__ . . Addirional _� .. .... _ � ... . - � -- --- ___ _-- � FotafNa. .__ . .-.. .__ - CifY - -�__ FeI.No. DaFe� °ppliLont ... � ..... --. . FiiedApplia��ei Not.Ove�i HP. .. . p��7 . NQTtCE TQ AVPCICANT: if; aher makfng this Certifictrte of a��yNr �c Exemption,. you shoutd betome subject to:the"Wo"rkeis'. ��9e�Neater_D.W._ � � Compensntian prpvisiern of fhe laborE�e;-Yaumvst-7orth•- Oven _Qryer _W.M._,.� AQDRE with camply with :uct� provisions or this-permit shal�.be Top _FAU _W.H.— - deemed raveked_-� __-__ .__. ...__.. . � CITY • � FeI.No. _ ... -LICEAlSED CONTRACTORS6KLARATI6M � �od _Fan _pther_ rJ - tICENSE OR _. tkerPbyaffrr�nthatla�c-licensec!-under��proaisier�s�€EEo{�ter4 . .Qisp. _RacmAirCand. — REG.NUhteER. � Cla . �(tornmencing wftk beetivrt 7000p of�ivis�on 3 a£the�8usiness - - €SISTRlCT NO.- PROCESSEQ 8Y - and Proftssions Gode,and�-license Fs fa£ul4 force and�effect. Power-Apparalus�Carge Appliances Y . -�� � - �� Size @�Fype HF,KW,KVA,or KYAR �� Q � [icense Num4rer . 42d74g . ..Lic.Clau �-�Q . . . . . - FINAC - V _ . Up to 1 trtcl. E��L'l.Cd�� � Date ��ZZ-�5 .. . Qver t to 1Q Md. _ ----- DA�� �L`;��'�r'�,, �AUDATI6N 0 � fonkractor Over IO fo 50 kncl. � � ❑ - . fINRE . . . . I om eaem{a�under Sec. Over 50 to 100 Inc. BY � � . B.&P.C.for this reasoo Ove�100 `�"`-����'�"'-"� V�1 - � - Servites,Swbd..MCC&Partetboards � � Z � Date: 0-2IX?Am Under 600 V � -: Signoture 201-1000 Amp.Under 60Q Y - z� ��'b A � QOver 100Q Amp.or f>ver 600 V �. � #��.� •-• �`� . Exemption for Req.Mairtt.E�ect. �� �._ SWGLE FAMIIY �emp.Power Fole 8 Appur4enances � � � •� G�5� � HOME OWNER-BUfLDER DECLARATION Si n with One Bronch Circuit - I hereby affirm that I am ezempi from the Contractor's License 9 _ . • • � Q��Q c=> - � low£or the Fot(owing-reosort(Sectton 7031.5,Busirtesa and Additional Sign Brartch Circuiis . . . . c , .ProfesfionsCode}:.. � -. Q 7 L..�-B 'rJ �� ❑ 1,as owner of the properry,will do the work ond-the �x•eonduits&Cortductors � - - �structure is not intended or oifered for saie (Seciion Qfher(See Compiete Fee Sched�le)- ► 7Q44,Busineu and Professions Codej. CONSTRUCTION tENDlNG AGENCY � � . - � I hereby affirm ihat there is a construction lereding agency for . - the pedarmance of ihe work for which this permit is issued PERMfT FEE (Sub-Tota!) .. (Sec.3097,Civ.C.}. . . . ... � . . . . -. . � - - PLRN CHECKIiJG FEE - . Cender s Name _ -. ... - . . � � - - PERMIT 15SUfNG F€€--� - lender'z Addreu ._... --_ . .... . ... . � __ _ ... ___.. .. .. . .. , --- . � � TDTPd.FEE_ � - l certtfy thot I hove read this application and sEate�fhat ttze�: - --- ---- , - ... : . _ . .. above information is corred.i agrse to eomply.�Ithhft County. � . - . - � - . .. -. ... . . ..-.-- . ��--� . ordinanees ond State-lows regutating.Eiectritaf wuing.�and. . .. . . - .... . . ... . ... -. .._. ...... . hgraby authorize represenwtives of this County�o enter upon� � - . � �he above•mentioned property foo inspedian purposes. � � - - � �, ///,� � ��_� t SEE REVERSE FOR EICPlAN/iIQRY Lpl1GUAGE--.- '�^''�'��€ c � � � �Signature of Permitfee- � ' Da e ` _. . �# ,, �.� , x oo�'o � . b� � cas w �, ' c , -o G . a m w m C c� . h. A Q` �p .C p �' q'Cf,S,.� . . 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