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HomeMy WebLinkAbout1369A R � NORKERS'COMPENSATION DECLFlFATION asAesa ime� �^ � � _ `� I hcreby af irm[hai I hx✓c a c,crtificate of consent to sclf insure �CEaosG AppL�CAi 90riol rvFi ELE�.,i'i�iC�L REF'sfiliiT �. or a certiti ate��of Wnrkers Coinpeuatlon tnsurance,or a certified ' COUNTY OF LO$ANGELES BUILDING AND SAFETY .coUY thareof(Sec.3800,Lab.C.i � � - _PO�I�ICy NO. Company FOft lPPLICANT TO FILL IM � .10'3 -p �f '�- . Certf-d copy is h e6y furnishcd EACH NO. FLF A������� {<G "� ��'�9� �E .New Residenlial�Idgs.&Pe is 1 . �i❑��CeiGfi�a copy is filed�"with 4he county buiiding inspection �&2-Family,SU.Ft �u — 5 LGCALITY � ���J�� 10� j�,i�l� ;� �dep2rtment � Multi-family Sq.Ft. — ��,� �� i �� . �NCA�EST ;-� ` j� � - -� - � Resfdential Swimming PQols +--+ CFOS3 ST. �'� ��m� '��`�y.E ?} �Date � Applicant .,,+' � ,r� :-:.CEP.TIFICATE OF-.EXEM14 _ �I'�� - .nRM NAM[-�.�/'s`�e�{y'' a5J����''� ��°y"d.i�G�,/ � � PTION-FROM VJOAKERS :-:. 'Outlets:�Rcc�Light—Sw.— .: .:� MA�.- -�j- ��,,/ it'"`- � � , .- _ GOMPENSATippd!NSI�RANGE . �� nooaes .,�d,3 . �r• � �. .{This��sectionneecl:�ot be cpmpleted it 3he-wor�C-involved:by tbe Fir.st?0 .. � .,..� --� .,permit is for,one hundred dollars($�00).or Iess.) lotal No. Adtlitional CITY �p -• �•� Tcl.Nr�,.^',a%�=��:.s'`�.s,`,�✓`*p+'� PLAN CHE(,"K �I certity that in thb Performance ot the work tor which this pe�nit qppLICANT _ F4,�] :is i55ued.i Snall not erpoy 2ny.person.in a�y.manne[So a5 to � � �-become suUject to tha Woixers'Compensa6on Laws- �tighhny Fxtures �irst 20 ' ADDRESS � � � lotal No Additionel I � � GiTY Tel.�o - Date�_ Aop!ro2nt Fxcd Applianccs Not Ovcr 7 HP � �NOTIGE TO APPLIGAfv . lf, after makina this Certific re o£ PcRMii - �' a r �s`�a ��F� _ :Exemption,youshould hecome subject m the Worke.:Con�pen,acion R�nge _ Heatc.v_ D.W. _ APPLICANT '�^`f�`'�-�' P"z'. r��.' � ,pmvisions o`the LaSo�Coac ;ou must forthv�th comply evith such Oven_ �ryer_ VJ.M._ ' ADDRESS � a+j� ��P*..-� �� . ,provisior.s c-th�s nerni t shall he raemed eooked Top _ FAU _ W H.____ � � � IICENS'ED GQNTRACTORS DECIAllAT10N Hood— Fan nther_ ���v �3� =}��"t�,'`,�-p^'✓P -� � Tei.Nq�/-���.�'°�� � I hereby affir^�tha'.I am!ice^,sed unuer prov.�ons of Chap+r 9 Disp. — Room Air Gond. — ! ��CtNSE oa ,� . _ (wmmenc vidh S�cto,i000)of D(vision 3 of thc B� �nes:.and REG.NUM9ER ���=� � � ProfeSGions Code;antl nyiicense�s in fuli force antl effect. .power Apparatus F.Larc�e ARP��ances I DIsfRIGT Na PROCESSr�nv 't � � . Size&Type HP,KW,KVA,or KVAR �� b�- -� License Number._____ ____—Lia Class_ llp to t Inr,l. �FINA� (j p - Over 7 to 10�nci. � DATE # � ���Contractor Date - Over 70 te 50 lncL --�— — . .VALlDATION O ��,g FINAL� -. }— - :�} - ❑ 1 am exempt unde=Sea Over 50 to 100 Inc. � gy - . (} . B.&P.Q Por this reason__`__ . Ove�100 .. . �.. - ��Services S�vbd MCG&Panelboa.rds � .- ¢ Date: 0 200 Amp.Uncer fl00 V � �� �:iz!rf .� �.§ Sign2ture 201-1000 Amp.Undcr 600 V � � . ' �g .. .. ❑ � . . . Over 1000 AmP.or Over800 V . �....� %'{� ��� � m% - . # F_�mption foi�Reg.i�Aaint Eicct � � ; .. .:-$ ,� �Z.�,�� - : _ SINGLE FAMILY Temp.Po�r�er Pole&Appu!tenances - " ,. i HO'JE O�VNER HUIi DER�ECLARATION �Si n witli One Branch C�rcuit -- e �� ' �,n=� � � I hereby afirm th�t I arr exer�pt fron the Contractors Lioense law g `J t` '`'" � - �-- �or the ieilovrng reaaon(.,aaio.i r O.,S.S,Eusiness and Prcfessio�s Addition��Sign Branch Circuits - f � '"� .-_Code): . .�.�G, U f_'"S4 l: . {�p` �Misc Conduits 8 Gonductors ; .. .. . �t I,as o;�vner ot the p operty w I do the work and the siructura is not m?ended or uf(ered`or sale(5ection 7044,Business Other(See Complete Fee Schedule) — , '�� �- , , and Profesaiona Coda� �` � - � '- CONSTFUCTIQN'.IENDING.:AGENCY � I �"R��/4� . � �� �hereby aFfirm that there is a�construction lending,�flency for the . � _ -- - � erfonnance of the woiic for whfch thfs permit is iss��(�ea 3099, y'pERMIT FEE- .(Sub-To+aU` , �� �f.a ..: �� ' ��,�,��,r�'�;,�,� -"� tv.�?5�-,. � . . . . � . .. . . ..;_ .. . . . _ ' . ._ . -. « "� � � . PLAN CHECKING FEE ,, � - � Lender's Name � __.__ ___. _ — � - � -.��:-�- �PERMIT ISSUING FEE �tiJ L��nder'sAddress rk ,., � . I ctirtify that I�ave read tli;3zpplication antl state that thz aUove ��TOTAL FEE , „��,i�:� mfCrmation is corr$t�ag s t¢co,mply wj�h all Courty ordinances . � � and'.Stflte.aws �c�u!a . lectric�wiY g, and h�,rcby authnrize � repr sen �3�s yauilv�(vr'ent upon the above-mentioned � „' prope�py �r eCti �r es. g � � . SEE REVERSE FOR ERPLANATORY LANGUAGE . � �A�/,��� ��"�� 4 Si a uro aS PErmitt� Date � � /� A p. 4} V,` Cu �h J J� Cn, " � € - � �'°�n.,..e r � � s:. ,5.. C - �O �Y ` u ,.c - { I - . . � � �' . � J � IXS C' j �i y ,Ci ( . . + ,'. c. �. q � `'� � °' � N. ri`.}�, a � � ca `"� �; � � : � . . . . . . - E we��,� , -' w cr -3 h � , e �.. �;, � � > I " . - . . .: � . - ;p � � ,,, � ��.. � . . : ,�. 3 � � J -� . .. � f# �. 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