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HomeMy WebLinkAbout1668A _ _ - - _ - - - � WORKERS'COMPENSATION DECLARATlON _� -� ��-�o�8t ��pp��CATtf�E� Ffll� E���TR�C,�l.. PEltll�llT - � � t hereby offirm tfwt t hnve�certificute oP conseof to seif -.- . .- - _- -- . -. . �- . I Ensore,or a cenificate af Workers'Compensahon Insurance, COUNTY QF�QS ANStELES _ BUILDING AND SAFETY or G cerh#iedcopy thereof.(Sec-.3flQQ,1nb-t-) � -�-: . . . . . .- . . . . . ._ .... _ _ .. . .. . . .. . . ... . Policy No:C`2?77dflSfaompany 1I8A ;_w�t A►vuc�Nr iOsut_iat_. .:,. �-.. �os ::- � aDtSRESS__ _....�_ ,_: . _.. -��� :� Cereifted eopy is hereby�4ufnis�ed. -.-: '- - -� New Residentio181dgs. P - '�'��� �`-_ � �.- -- . l t&2-Fomii 5 FY,',$�� ; . — � LQCAII. -- - GerYified copy is filed.with the coanty borlding;inspec- . _ Y- 4� - : � __. . . . . 4ion deparkm9nt.- . - . � - .. . .-.MVifi-#amily$4_ft ..-_ -_. . ,- NEAREST.-, '`-.- ` ' . . . ... ... . � . ... �.. _- . ._ _ . _�. L7tOSS�_ .�... _ ... .� . � �� �r �� . Residentiaf Swimminp Pools � � py�ENERqt � - � , Dote �J���HS Appliwnt 1 � � .. . __ Ha,.a�ia+u�At�d�i_-=G�c2Lt.--.� . --- -- - _ �.CERiLFiCA'tF_E3Ff�(EMRTK?t•tPRQM�NORIGERS"' ' _._ __ __ .,_ .- _._- -_ �L----- -- - _ ._ _ __. - - . �COMPENSAFJON FNSURANCE� ' . ' - butfeh:.Qec_lgh! Svr'_ . _ - ABDRE55- - .. -. .. (Tkks-section nw�aot44 compfotal FF Me work iarolr�d 6y ... F"$fi�0 .. C�TY `:' - . .. Tet . . fha pormif is for oia hundrrd dollors(Si00�or le�s.j �Qtn(No q��{�;�� _ _ 1 A ara c+�cx - ' � 1 certify that in tf�e per€wmance af the work f�.wliich this .. . .. - ,yppucArii � j , �permif is issuedF f shafl nat emptay uny person rn on}�rtwnner �- -� � . - - - .--. .- . . ..- _. ._ _. .. - ° so as to 6ecome su6ject 10 the�Work�rs'Compeosation Laws. �- <i4h�ing Fixtures �- f'vsf?0 --- - —�1Q@BES� - -- - � + . . . ... ._._ .___ _ .. ._. _.: Rdd;fio3aF -._ _ . -_- . . � Total No. CITY fel.No: .. Date A PlFcnnt - - � hx�Applionces NotOver f�HP- vERMti. . �. NOTiCE TO�-APPt1CANi If afrer mak ng-this Certificate af ���� � - -� - APRICAMu�R � � � � ._ Exemption. Yov sMouW become subjett £o the.YYorkers' .-_ RQnge.�HeateC-�D.W._ � n'�r.r�-.� . � H. .. Eompensation��ovisiom�af-the lnbor Coda;yov must-forth-.--� --�veo.��[try��_W.M_� . . . . . A�SDRE$5.. � with comply with.such provisio�s ar ihis permiw ahatl 6e �-. top=._._FAt7_.._W.1}. ..-.-,._ - . . -. __. . :-. deemeet revoked_, -_ r - -- CITY= . • " TeL N . ` ..- -- -- Hood--=Pan � -_Ofber-_ - � - LICENSED CONTRACTOBS DECEARATION . ttCENSE OR � ifterehyaffirmahat-Famlicer+seduaderpravEsioaaat�hapt�r9. Qisp. _RoomAir.Cond. — REG.FdUMeER 42Q7�$ Class(�'��(} (commencing.wlth Secrian�Z00Q)of Divisian 3 af�the.Business DISTRtGT NO. PRQC€SSEU BY � .� � andProfessions Caie,ortd my:license-is in-feell tqreeand.effect. Power Apparatus 8large Appliartces . qY. ,: �� . � � - Size&Type HP,KW,KVA,or KVAR - � I� Q s License N�mber 47���� F+c.Elass�`•-Z 0 FlNAC V � . . Up to i Ind. . :� � Over 1 to IO lnd. DAtE - � '� Eonnaper FIE�'�riC11-- � t3ote- ��� :.- .-- . _._ IA-���.-�5_ .;YAt@ATKJN_-_= - . Q - - ��3 - aver=io ro 5a tncf. �-- __ ---. -._ . � . F•.. j � �-.� . .. __ ... _- - - _- -- . . FiNAL � -- � f ` I am exempf.under Sec. 6ver 50�0 100 Inc. . ._ BY �_ � � � '- -_ -` ---- .. .. . _.. .___. ._.. .. . _-- -- -- __ ... --- -- - . s. B.BP.C,for�this reasorr��. . Over TQ6 -�- -- -- -_ -�.�-�_ _'... -_. � :.: . . .. .- ---. ... .--...- - - ...- Se�vices,Swbcf.,MCC&Pnnelboards � . -Date' . 6-2510 Amp.Urider 600 V .. _ . . .: ... ..$ignoture , .201-7000 Amp.Under 600 V - ��. .� .. � Over 1006 Amp.or Over 60Q Y . 2 1 6 d 8 A Exemptio�for Reg.Maint Elect. ___.._._ _.----- -._. � ----- ___. SWGIE FAMItY .�... ..�--. Temp.Aower-Po{e&Ap�uAena�ces-.. . ..._. _ . ._._ � #r.♦ s.• �� � HOME OWNER-BUIL�ER OEQARATION St R with Qne&anch Circoir - - t�hereby affirm thdt i am ezempt from the Contracta�s ticense - 9 � • � Q�5� - . Law€er the#ai4c+vring reason(Settion 7Q37.5,Bvsiness ond �ditional Sign Branch Eircuits . .. . _- � Profesxians Code):�_ - . . . - . . • � 7 U�,s d c: �� ❑ 1,as owner ot the ro ert will do the work ond the Misc.Conduits 8 Conductors - - P P y' O�e�.See.C�en leie Fee.Schedule_ �7�����5 � structure�is-not intended or offered-£or sale(Seciion-� � P � ---- - 7044,-Business and Professions Code). CONSTRUCTION LENDING AGENCY � �� -- � - . __ _._---- -_.._.__ .__..___ ._-_ .. -___..__ .._. ... . .. . . _ .. . .. . _ _. _ _ .. . . ---_._ .. _.. ..__ -.__---- -- - i hereby affirm that tf�ere is a�consnoction lending agency for � � � �he perforrrwrtce of ihe wwk#or which�rhis permio is issued � p€RMIT FE€"" .�� (Sub-Total) - (Sec 3697.Civ.C}. - . . - ��- fLAN�CHECKiNG FEE �- - . Lender's Name � � - � � � PERMtT tSSUiNG FEE . . - Lenders Address - . i.+� � -I certF#y rhar 4 have read tbis applicatlon and state thnt the TOTAL FEE FJ(J _ � a6ove in4ormotion is correct.I agree ro comply with att County -. � ordinances.and State losvs.regutating Electrical wiring,.ond _ - hereby authorize representatires of ihis County)a enter upon� �- . �. � the bove-me�tioned property for inspection purposes. SEE REVfRSE FOR EXP�ANATORY LANGUAGE � �7�� \ Signature of PermiFtee �Date � � - � , _ _ _.. _ r��...-_ . _ # ��. ;" w�'.cmd�wH = o ' m c u �� oo,i�° . ° ,a,o � o 3M ° av` ° ° �» mc+- a ' ' a� N �o �o-cmnc .Y � o « � c,°c .� =� ma� c � a .,rd. v' m.c' `o U° `ym °a ° o 0 0 ��° � c ° c ct�o� m 3. mv.a .�.�mc U .- o �_ mac � � tito � a V .� m— � � Z � W u � ? C �-� � n C G u•� F p�" 0 S y L � fi d � � � - . ., 'O �` opapOBmE °='.c p " 3 .� $ > a F- � etv�W o-� c o o�.+ v°� � � .:,.. o,w a , oc � E ' '��""m °+ =-o � c ° > � ao . Q � �- `� p Pm m > E ` 3 a`01i `V" b o �3 w c o . 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