HomeMy WebLinkAbout0843A 5532B � ,�vg.�s j�cr.-ch'���:�, �
WORKERS'COMPENSATION DECIARATION 7 IO/el � .
1 hereby oHirm thot I have a cenifimta of conseN ro self ,+� _ APPUCATION FOR ELECTRICAL PERMIT
insure,or a cartilicate of Workars'Compensation Ina�ronce.(? COUNTY OF LOS ANGELES BUILDI G � AF � �
� or a certified copy thereof(Sec.3800,Lob.C.) � �
P❑olicy No.�_Company.SAa"IE- F,vn/l� � fOR APPLIGM TD Fl0.1N . � JOB � J �
� Certified c n hereb furnished. EACH NO. FEE A��RESS U . ��.
°F'V� Y New Reydential 61dgs.8 Pools
.2=Fami1 FL = — f LOCALIT��yy�,� .,.�yti1�.
�'Certified copy is filed wi1F Ih ouM � uilding ins Y.59• _
tiOn epaf� nt. ulti•fomily$q.Ff. NEAREST _
CROSS ST.
�� Residential Swimming Pools OWNER OR - � �
Date Applitant � FIRM NAME � - ��
CERTIFICATE OF EREMPTION FROM WORKERS' . Mnil �
Outle�s:Rec_Light_Sw.`
. � � COMPENSATION INSURANCE ' � � ' First 20 � �RE55
(Thls�Mlen eNd not b�eompl�t�d if ih�work inmlv.d b� Total No. AddHionol CIN . Tel.No.
Ihe permil i�for ona hundnd dollan(5100)or le�a.)
PL4N CHKK
I certify that in�he performaace of the work fw which this � ' qpp���qNT j � �C'i �,�-
- permit is issued,I shall nof employ any person in ony monner � �
so as lo become subject to�he Wakers'Compensation laws. L�9hring Fixtures Firat - ADDRESS 7J� ,S` ���iLi..+ —
� . � .. Torol No. � �d�nal
CITY {,�q_ Tel.N���957� ,
Oate opplicoril � � Fiaed Appliontas Not Ov r pERMiT
NOTICE TO APPLICANT; If, ofter m6king ihis Cerlifimte of APPLICANT '�- �'
Exemp�ion, you should become subject to fhe Workers' Range—Heo�er . . .
Compensation provisions of the Lo6or Code,you must forlh- Oven _pryer ..._ .M. � ADDRESS � - � _ - � -
with mmply with suth pro0isions�or fhis permit shall 6e 7op _FAU W.H.�.
� deemed revoked. � Hood _Fa _Oiy,d CITY - Tel.No.
� . LICENSED CONTRACTORS DECLARATION ��. � ///���v uCENSE OR
Disp. _ m Ai�C`qd. — . ss. .
I hereby affirm�hot I am licensed under provisions of Chapter 9 REG.NUMBER /�
(commencing with Secfion 7000)of Division 3 of the Business � . DISTRICT NO. PRk�E55�BY
ond Profeuionz Code,and my litense is(n full force and effecf. Power rafus 8 La Appliances /� �
, 3���� .. � Size 8 Type HP,KW�VA,or KVAR' pL— 0
License Number ��Lic.Class� � � FINAL �� -- � V
�` . . Up to 1�ncl. .. - .
��t / Z �� Over 1 l0 10 Ind. DA� � YALIDAiION Q
/\ CoNracror�Sk l'�[-f�2_.�f pate 'Z- �^� Over 70 to 50 Incl. . . �
❑ FINAL
I am ezempt under Sec. �_ Ovar SO to 100 Inc. BY �;��f.;,� W
8.&P.C.for ihis reason Over 100 .,, e o ,., vai
_ . Servicea,Swbd.,MCC B Panelboards �1 -. - .�`''°. . '- Z
Date: 0-20p Amp.Under 600 V � /7 � � ����.�;j(?�r'j ,
. Signoture � � 401-1000 Amp:Under 600 V� ' --� - � - -�� '
❑ � . � �Over 1000 Amp.or Over 600 V _ , - -_... . .. " 'L�` .r l,-� .
Exemption for Reg.Moini.EIeU. � tJ J/^_^
SINGIE FAMILY � Temp.Power Pole 8 Appurtenancet.. � "� �
- HOME OWNER-BUIIDER DECLARATION - - Sign wi�h One Branch Circuii � � - - - �
I here6y otfirm that I am exempt from the Conhactor's License Additional Siqn Branth Circuits �
Law for the follawing reoson�Setlion 7031.5,Business ond " �- . � -
Professions Code): . � � � �
� � Mix.Conduiis 8 Conductws � � � � '�- � � �----- -� � - ''
�,as owner of fhe property,wfll do rhe work ond the �
strocture is no1 intended or offered for sale(Section . O�her($ee Complefe Fee Schedule)_ , . ��.
70t4,Business ond Professions Code). � ' �
CONSTRUCTION LENDING AGENCY - . -� �- �- � - � � - - �
1 hereby aHirm that thare is a comtruction lending agenty for . � . .
the parformance of the work for which this permit is issued pERMIT FEE � , � . (Sub-Toro1J � � � - . __
(Sec.3097.Civ.C.J. _ ' - � �
- . . . PLAN CNECKING FEE � -�- �� � � �l�j. .. .._._ . �
Lender's Nome . � .:._ .
PERMIT ISSUING FEE- - -� . � � �
Lender i Address � . • � N • ��,� • r'� ..
707aLfEE � � o -" cn
I tertity rhm I have read this applimtion and stote thot the � � ,- „, Q. �� ;� � ..
obove information is correct.1 ogree ro comply wi�h oll County �, � �� � �,� - -
ordinonces,and Stote laws regoloting Electrical wtring,and . � p Q � n� ' � �
hereby outfio�ize represen twes of this County to eNer upon �- �- � -
tl( b e-menrioned pr erty{�inspection porposes, � t� O C -O Co
� - SEE REVERSE FOR EXPLANATORY LANGUAGE. � �fa (� j�C
l. �� 2-ZY��`� ���� �p�� � � .
, Sig ture of Per 'tee Date _ . - � S LQ �
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