HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECIARATION � 76A663 10/8I qpp��CAT10N FOR ELECTRICAL PERMIT � �
I hereby offirm thar I have a cerrificate of consent to self CE-eOeG � ,:
insure,or a certifcme of Workeri Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certified copy thereoi(Sec.3800,Lab.C.J
P❑olity No. �'��1Q(197 9(jompany- �Tj� � FON APPUCAM TO F�IL IN � - J09 � _ . '.
Certified topy is hereby fornished. New Residentiol Bldgs.8 Pools EACH NO. FEE . ADDRESS ��
� 'Certified topy i3(iled with the counry building inspec- �g 2-Family,Sq.Fi. - ����� S — s � ��'4L1TM
rion departmenf. - Mulli-family Sq,R. — NEARESi .
[RO55 ST.
Dote 8�8�83� Applicant°C°� MCGC2 EZEC�TiC Residential Swimming Pools - pWNER OR -
� . . FIRM NAMM�J Srock & Sons
� CERTIFICCOMPENSATION INSU AN EORKERS' � Outlets:Rec_light_Sw._ .� � , � � ADD'cE55 1698 �
This sacllon nesd no1 b�com bt6d if Ibe work tnrolrad 6 First 20 .
( P y Totol No.�_ Addirional � CITY . : . Tel.No �
fhe parmit is For ono hundnd dollars(S100J or lass.) PIAN CHECK -
I certify rhot in the performonce of Ihe work for which rhis - qpp�iuM -
_ � permit is Issued,I sholl not employ any person in ony manner
so as to become subjetl to the Workers'Compensotion Laws. �ighfing Fix�ures First 20 �7 ADDRESS � - —
� � � � � � �� �- Tmal No: 1 Additional .
� - CITY Tel.No.
Uofe epp�imnt � � � Fixed Applionces Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, oi�er making �hi5 Certifimte of q���M�� �� •
) \mption, you should 6arome su6jeU fo the Wo�keri � Range_Hearer_D.W._ .
4_ Jnpensafion provisions of fhe Labor Code,you inust forth• Oven _Dryer W.M._-�. - - ADDRESS 2390�S. Reservoir -
ith mmply with such provisians ar this permit sholl 6e Top _FAU �1 W.H.—
deemed revoked. - � � � . Hood —Fan _O�her_ � � - CITY - pOApAd r�i.No627-0936 -
. � �LICENSED CONTRACTORS DECLARATION� . � LICENSE OR -
I hereby affirm tho�I am licensed wder provisions of Chapter 9 Disp: —Room Ai�Cond. _ �� � � REG.NUMBER .].S33�IH - Class.. �
(commencinq with Section 7000)oF Divisian 3 of the Business DISTRICi NO. � PROC SED BY� .
and Professions Code,ond my license is in full force ond effect. Power Apparatus 8 Lorge Appliantes . _ ._ >. ,
- Size 8 Type HP,KW,KVA,or KVAR� � a
ticense Number �5��7R Lic.ClossC—ZQ � Up to l lnd, � PINAL - - � - - O
CoMractor Electrical Dote 8�8�83. .� -- , Over i to 10 Ind. DATE ���.��`� VALIDATION . .. �
.O Ove�10 ro 501nd.. FINAL � . ~ .
I am e�empt vnder Sec. Over 50 to 100 Inc, BY . _,, � a
8.8P.C.for this reason �Over 100 � wf ,
. . . Services;Swbd.,MCC&Ponelboards � , - �-� � � - -- z
Date: 0-200 Amp.Under 60D V . . '
Signature ZOl•1000 Amp.Under 5W V � � �� - �—�� � � ���
❑ � Over 1000 Amp,or Over 600 V .
Exemption for Reg.MainL Elecf.
� SINGLE FAMILY . Temp.Powe�Po�e 8 Appvrtenances .
'HOME OWNER•BUILDER�ECLARATION Sign with Ona Bronch Cirtuit '��9�6�
' (eby affirm 7hot�om exempt from the Contractor's Litense Additional Sign Branch Circuits , +{ie�
)for�he following reason(Settion 7091.5, Business and -•• • •2-
'ProTesstons Code): � � .
❑ I,as owner of the properry,will do ihe work and the � M;it.Conduirs 8 Conductors � � �- �-� � - ��- ����-� �� •-1 0 n 5 3 �
struUure is nof intended or offered for sale(Section Other(See Complete Fee Schedule)_ , �� T
7044,B�siness and Professions Code). � �
�`1 C65��-
� CONSTRUCTION LENDING AGENCY . � .. . .O II.� 2—H 3
I heraby affirm Ihot there is a consfruclion lending agency for . ,
the performance of Ihe work for which ihis pe�mit is issued � PERMIT FEE - � �� (Sub-Totalj� . . ._ . _ . .. _ _ .
(Set.3097,Civ.C.). � .
� � PIAN CHECKING FEE � . .. . _. . . . . ._. ..
Lender'S Nome
� . PERMIT ISSUING FEE . ' .__ ... �I.O SO -
tender's Address � � � � � - - �--� � � �� �
1 certify that I have read this applimtion and smte that the TOTAL FEE � �1�6�.53 -
above informo ion is correct.I ogree to comply wiih all County � � -'-
ordin9nces d S�ate laws regula�ing EledNml wiring,and � . �
her y aut rize e resenratives of this Counry to enter opon � � � - � - - - - � - � �
th abov enr ned proper y or inspetlion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/ 8/8�83 _
/ na1 e of ermitree Date , .
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