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HomeMy WebLinkAbout1147A WORKERS'COh3pENSATIONDECLA[tAStON CE-806G12-80) APPLICATfON �OR ELECTRICAL PE�RMIT � �_f t hereby artirm that 1 he�e a rertif�cate oe consent to self COUNTY OF LOS ANGELES BUIL�ING AND SAPETY insure,or a certificate of�yorkers'Compensation Insuwnce,or � ' , a certiHed copy thereof(Sec.3800,Lab,C.) - � � �/��/��/� FREMONT INDEMNI Y FQR APPLILANS T�FlLL IIV-_ _ - JOB E Policy No.�_�mQany � A�DRESS New Residential BIdgS.&P0019 EACH NO. FEE ... .. . .. ._........_......_..... � :... � CeRified copyisTereby furnished.� �������� ��� � �� 1&2-Family,5q.Fc. � — $ LOCALITY DIAMOND BAR � �n Multi-family Sq.Ft. — N ST � � Certified copy is filed with t e�county b�ing ins ection CRO55 5T �/'G�-e-•-✓ depar)ment. Re�idential Swimming Poois owNER OR �� � FIRM NAME Uate f APP��4a . Ou�ets:Rec.�Light_Sw._ MA1l 2Z12'7 RI�'i I� '� First 20 AOORESS CE TIFICATE OF EXEMpTlON FROM WORKERS' Total No. Additional CITY Tal No 7 ! _ ,__ COMYENSAIION ENSURANCE P4AN CHEGK �' I APPLICANT W�N�T PBOLS U (This sectian need not he compleied 'J ihe work involved Lighting Fixtures First 20 ADORESS by lhe pecmit is foc one hundzed dollars(S100)oe less.) LDEN SP INGS � Additio�al . Total No. GTY WALNUT Tai No595-7547 �� f certify t6at in the pert'otmence of ihe wock for which this pixed Appliance3 Not Over 1 HP (� pe�mit is iesued,t shall not employ arty�person in any manner PEflM1T . W so as to become aubject to the Worke�s'�Compensation Laws. Range_Heater D.W._ APPLICANT UT POOLS 6. � Oven _Oryer_W.M._ A�ORESS 21450 GOLDEN SPRINGS z Date Applicant - Top _FAU _W.H.._ — � Hood_Pan _Other_ CITY Te1 No�9r,-7547 NOT[CE TO APPLiCANT:[t,aflm mnking this CertiCcate ot p�sp, _Room Air Cond._ LICEiJSE OR . Exemption, you should become subject to [he Workers' - REG.NUMBER 319018 �lass 53 Compensa[ion Qrovisions of[he�.abo�Code,yau must forth- power Apparatus&Large Appliances DtSTRICT NO.�/ PAOCES D Bv.. with comPty with such provisions�oe�this permit-shatl be . _... .._... .-.. " ......... .. . . � deemed revoked. � Size&Type HP,KW,KVA,or KVAR Q Up[0 7 Incl. � FlNAL Over i to 10 Inc�. onre �" S �JZ VALIOATION LICENSED CONSRACTORS�ECLARAT[ON Over 10 to 50 Incl. �� t hereby affirm that[am licensed under provisions ot Chapter Over 50 to 100 Inc. By p'� , 9 (eommencing with Section 7000)af Division 3 of the Busi- Over 100 � • ness and Professio Cude, my►icense is in fnii force and . effect. �,/ J/ � ,p Services �/�a �� �- '� ,�.e�ll�,j.�/. � � / � �3 4200 Amp.Under 60p V � � v / / License Numbe ia Class v�'S- ��L(ta✓��.�./ � 207-tOQO Amp.Under 600 V �Contractor Y Over 1000 Amp.or Over 600 V � r HOME OWNER-BUILDER DECLARATIO Temp.Power Pole&Appurtenances . � ( hereby aFfirm that t am exempt from the Contractor's Sign whh One Brench Circuit � ' � �License Law for the-following reason (Section 703t.5, Busi� A��tional Sign Branefi Cireuits � - . .. .-.; _..... . .:.::.. �nessand Rofessions Code): - ��� -- �� -��----� � . ...._.. ... .._._..... ._.... _................. ... . - �........ � . . .- . .. . .... ..�............:...... .. �Misc;Contluits�&�Conductors ..... . ........_.. . .. ...... .... i� I,as owner pf the propecty,w�ll do the work and the Other(5ee ComplcKe Fee SthedUlei— � , , . � 7 structure is not intended ot offCred for sale (Section 2'�_����7 A 7044,Business and Professions Code). � � CONSTRUCT[ON LENDING AUENCY . �� �,� � �2 , •I hereby affirm thyt ihere is a consi�uction Iending agmcy ' � ��"'� � for the performxnce of the work for which thia permit �s � pEpM1T FEE ISub-Total) � • �2 8 5� t issued(Sec.3099,Civ.C J. �d �Lender's Name PLAN CHECKING PEE (One-Fourth Permit Fee) •.• •2 g.5�� I � Lender's Addreas PERMIT ISSUING FEE i 2 2 9-81 1 cutity that 7 have read thi5 application and state that [he TOTAL FEE � above inform�iion is cormct.1 agree to compiy with aii CountY . . _ . . . . - ������-�-�-- �-�-- � � �� � .._. ... ..... rdinaneesl$u4� State laws re uteting Electrlcal wiring, and � � .hereby ai(H[ori2e representayf4�of this County to enter upon . . . - he ve-mentioned pro r�ty for insDection purposes.. - SEE"REVERSE FOR EXPLANATORY LANGUAGE �� ----- _.. -- ' iynature oi �er�it ee Dat - 1 .. ..�'''fi ��• .�� /�%/F - _ °.� ' . �,� � Y,�� i � • _ ? o cv o � ,.G.., . . . . _ . . � 'O ..�O q � ��.C, - � . . . i a � V d p m � a, . .. e� C ��',,.. .v s s �y d M o � . . ♦ , es °i� .'�+ �`'t v o� � `� O 3 4 C O C1 . , . . . . . ,,N.y.y."' y w-+�1t C L`O � � T�L [`'t � � " . . . ✓�v1 '1 .+ p 4�, b 6 � � U � o�C O"' . 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