HomeMy WebLinkAbout1667A � . WORKERS'fOMPENSATiON DECCARATION -76A663 �Orei �R��1e���ON EOR EI.ECTRICA! PERMiT �
- I here6y nffirm that I have a certificate of mnsent�o self �-�G
iasure,or o certiflcvte of Workers'Compensotion msurance, CQUNTY 4F LOS ANGELES BUILDING APID SAFETY
or p certified_copy ihereof(Sec 3800,Lab.C.) - . .
Policy t�?77'7G(Iri(I Company. TNA . - FOH APPLICA#1T TO-HLl1N - JQB �
. �<� rtified copy is hereEty furnished. � - New Residentiai 81dgs- ots �-�'�-` �O. � F€€- -- ADDRE ' '
t&2-Famil S — E IOCAII
��rtified copy it fifed with-the tovnty lwifding�inspeo- Y•54- � � .
�tion deporFment � - � Multi-4nmify Sq.R. — NEAREST . �
� �� H - Residerttiaf Swimming Poots ��St._
oare 7-22-85 aPvi�ro�r m �vi^f�F'.1� FTFY�Pf2T(,' OWNEROR
� - fiRM NAM€ �
�� � - CERTIfICkTE OFfXEMPTtpN FROM WORKE&5 � pu�le�s:Rec_�ighlJSw.� ��«
.. � � -COMPENSATI6M IPISURANCE Frst 20 A��
(TMis soction aaad not 6�m�ep{etad if ih�work inrotved by Tokal Na. Adcfitional C47Y T 67-95
- th�p�rmit is for on�huwdnd dollers(Sf00)or(esa.f .
� - i certi that in the rfarmance�af�Fhe�wwk for which this . � �� P��� � �
fY Pe � A�PIICANT �.
- -parmit-is issued,--(sF�all not employ ony person in ony manaer .
so.as to 6ecome wbject tothe Workers'fomperswtion Laws. 179hfing fixtures . �irst 2b� ADDRES$
� Total No. additional � �
C1TY Tel.No.
-pafe - A�Iicant .. � Fixed Appliances Not Over i HP PERMIi
NdFICE T6 APV€lCdF�FT:1f,-after-making-this Eertfficnte�of - qp�i�NT �� ��
Exemptiort, ypu-shouMd became�sub}ed to the Workers' Range._Heater,_D,W. _ - . _
- Compensateon pravisions�of-the[abor-C6de;you�mu57"forth- - Oven _Oryer _W.M._ � A66RESS 111
� with comply witb such provis�ons or this permii skwfl be Top �PAU —W.H.—
cteen:ed re oked-._, ._.-. -,._... --�--� � CITY- � . - Tet.No. �
- LkCEN5E0 CONTRAC70R5 4ECtARATION Hood ,Fan _Other_ -
Disp. __._Room Air Cood. _ �����R Class
1 he�ebp vffmn tfwt t am ircensed underprovrsiarts ot£hapter 4 R€G.Nt3M8ER -
... (cnmmericmg.wuh.Section 70F70)of tkwswn-3-of-the-�8us'rr�ess Powef Apparatus 8 targe Appliances OISTRICT NO. �h � PROCESSED BX- O �
and Professions Code,-ond my-lice�se�Jsirtty4X#orc�tmc}effeci:
- � � �� - � � Size&Type NP,KW,KYA,or KYAR� - V
. . license Numbet Q7n�4R Cic.Gass �-'��� � Up io t Inct. - � FIFJAF . . V �
Ovef 1 to 70 Fnd,. QA� �
. Contractor��'�"kral Date - 7-22-55 � . t<%-g=:r-`'�"�-�. YALlaXTWN a ]
Q - Qrer 16 to 56 Ind. � F- �
FINAf
f am exempi ur�der Sec. Over 5p to 100 inc BY uVi �
� - � B.&P.0 for this reaaon 6ver iW H
� ... Services,Swbd.,MCC 8 Panelbaards . � �. - � z
. - Qate: 0-2IX1 Amp.Under 60Q V � .
-- Signature - Z01-1000 Amp.Under 600 Y � �
. ❑ Over f 000 Amp.or Over 6W V �� (t�'�A
Ezsmption ior Reg.Maint.€lect. -
� SINGLE fAMILY . Terrtp.Power�Pofe��8 Appurtenances . � tj� s � e •�
: HOME QWNER-BUILDER DECLARATtON Sign wiih Oae Bwnth Circuit - �
- I hereby affirm that i am exempt from the Controctor's License ,qdd�tional Sign Branch Circoits ' � � G"'�"
Law for the followi�g reoson (Section T031.5, 8usineu w�d �� � �
'. Prufessio�s Code): - � � a e '� C,��,5�4
� - Misc.ConduiR&Candutlws � - '
. t,os owner of the property,wilf do the work ond the . F
sirunure ia not intended or offered for soie(Section - Other(See Compfete Fee Schedule)� � O 7 Z Jr'�H..
�. TP44,Business ond Professions Code). _
� Cf3N5TRUCTiON LEND4NG AGENCY - � .
. I hereby affirm that there is o consiruction fending ogency for
the perfortnance af the work for which ihis permit is issued PERMIT FEE � - - (S�b-Torol) � . -
f5ec.309i,Civ.C.). � - - �
� � PLAN CHECKING FEE �� �
. Lender's Name - �
� ➢ERMIT ISSUMG�FE€ - - � - .
lender's Address � �
: I certify that i have read this appliwtion and srote that the TOTAL FEE - � -
� above informolion is corred.I agree to comply wiih ail County
ordinances ond Srore Iaws regviatfng Eletttical wiring,-ond ' . . . . - � - -
hereby aothorize representatives of this County to enter upon
' the ooe-memion/ed property for inspec�ion purposes. -
`��� !J'.��Q�-�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigrwfvre of Permittee - Date - - �
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