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HomeMy WebLinkAbout0906A (4) ,.:. .,.;a.. � �,__ .�. :_..:.,. ;.s:� _ . .. - � ,,.. �.�,:a�3x. _.�.:. ,�. .. .��< �- ,. . . , ,., `WORKERS COMPENSATION DECLARATION � 76A663 t0 el ��,Y�;,�� � ��Q-� � ICAL PERMI'� I l��r�h„��(f�yn thqt I�q,e,a_,F�st�ilGoAe,.qf.consep.t,rq,self. CE-BDaG ! A :F4��t__EL�CTR .., � ,..,, .�_ ,: .. nsure,or a cer{ificate of Wo.kers'Compensation.lns�rance, COUNTY OP LOS ANGEIES . . .. . BUILDING AND SAFETY or a wertif'/ied copy thereof(Sec.3800, b.C.1 � � -�-_ ' ,'"��. ' ,":." "„. � ��-�� � ��� - - � � � � POlicy 5il�,o!,_�';����J'� \ :� P . .. .... _ �FOR iIPPLICANT TO FI[C IN� JO& ❑ EACH NO. FEE ADDRESS t Certified copy is reby furnished. Ne Residen+ial Bldgs.8 Pools �la �8 2-Fumll S R. b — S IOCAUTY �Certifled wpy is filed with the co n building inspec- Y• Q' _ NEARE57 �' � � � � tion de art ent. Multi-family Sq.Ft. CRCSS ST. � Residential Swimming Pools O�NNER OR Daf� � � ppliCAnt FIRM NAME p _ ,__, . CERTIFICATE OF PXEMPTiON FROM WORKERS' Oollets:Rec�light_Sw., � MAf� COMPENSATION INSURANCE ADDRE55 First 20 ,(Thjs seclioa need not be completed i11he work inrolved by 7o�al.No. Additional CITY Tel.No. the pqrmif,is Fo[Ot+a.hundred dollars($100)or less.) � - pLAN CHECK � � ��"� �� � I<e�ffy;ho���the perf.ormance of Ihe work for which this APP��_ICANT . �permit is iss�ied,I sholl nof employ any person in any manner ,.. so as N become 5ubjecr to Ihe Workers'Compensation Lpws. Lighting Fixfures First 20 ADDRE55 Total No. Additional CITV .Tel.No. Dare Applicanf Fixed Applionces Not Over 1 HP tii` NOTICE TO APPLICANT: If, after mak�ng this Cerrifiwte of '(Q� ~ Exemption, yau.should become subject to the Workers' Range_Heater_D.W.— • . . Compensation provisions.of the Labor Code,you must furth- Oven _Dryer W.M.— ' � ADDRE � N _ with comply w-�h such provisions or this permii shall be Top _FAU �-W.H.— � _ � deemed re�aked. Hood _Fan _Other_ ��TY Tel. ,IICEN$ED CONiRACTORS DECLARATION � UCENSE OR �q Clo . �hereby affirm that I am licensed under provis!ons of Chapter 9 Oisp., �Roa.m Air Cond. — RE6.NUMBER �� p (commencing with Seciion 7000)of Division 3 of the Business pawer Apporatus&Lorge Appliances i DISTRICT NO. PR�SED� Y and Professions Cod license is iq full force and effed. � d {/l/ Size 8 Type HP,KW,KVA,or KVAR 5� ' t i`�'l � License N�mber �������U<. lassv� Up to 1 Ind. � fINAL � l� 1(j'�� ,.� Over 1 to 10 Ind. DATE � a�� YAIIDATION � Con2r tor Da?e'� � � . � .... Over 1D ro 50 Ind. FINAL ❑. � V I om exempt under_Sec. �'3"-�'�'q Over 50!0 100 Inc BY � .._.. ,.,,,.„B,,.$sP C,,.fox„[his re.pson Over 1C0 H ` � � Services,Swbd.,MCC 8 Panelboards , ' �� . - -' � .................-.._.._.__._ .. Da1e: 0-2C0 Amp.Under 6C0 V � _ .. , . . Signature _ . 201-1000 Amp.Under 600 V -� ❑ Over 1CQ0 Amp,or Ove.600 V . Exemp7ion for Reg.Maint Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances . . � . . ,,,, „,. , ,HOME OWNER-BUILDER DECLARATION Sign witii One Sronch Circuit I hereby affirm that I pm exempt from the Contractor's License qdd��ional Sigr.Bcanch Ci�cui�s � � �, ,,,,,. Law for.ihe following reason(Sec�ion 7031.5, Business and � �%�.q�,(��. _ P�afessions Cade): � � . ❑ I,as owner of the property,will do the work and the Misc Cpnduits&Conduclors �.s u o e :�j structure is_not,�ntended or of`ered for sole(Seciion Olher(See Complete Fee Schedulel— � ,.... _. . '�s ' - � 7044,Business ond Professions Code). 1 � a C i,C�(: CONSTRUCTION LENDING AGENCY � . a 2�`�„i,c'i � I hereby affirm.)hqt there is o construction lending agency for _. . .. � ` ihe perfqrn7apce of Ihe work for which ihis permit is issued PERMfT FEE (Sub-To�al1 - ii 4 I L"�� (Sec.309L Civ.C.). � . PLAN CHECKING FEE - � � - � ...<.,,�AL�d�G.�.>�Am.�, .._ �. . . . , PERMIT ISSU!NG FEE � � . . . . , . , _ .. . .. ,. ..:le[�d,ef;s�4,dSlress t q � . . . I certify that I have read this applicalion and state fhat Ihe TOTAL FEE L-�,I QU -„ _ . , � ,. obove information is co�red.I agree io comply with all County�a�^•a��•�� ••. � �.^. . -, '-�� ���' , � � - . . . ordinances.ond State lows regolating Electrical wiring, ond , _ �. . � , � . � _ _ , _ hereby aoth 'ae reprasentotives.of ihis Coonty to enter�pon � . �'. � . � the ab e- ed properfy for inspect' n purposes.' � � . � � (�"jj ,��„(�g},/�$S�FQR.EXPlAdl1TORY LANGUAGE � �'fL `b ti�-��3 _�,.,��_�.,�.�_ Slgnature of Permiflee .. __ .Date ��. � � � - ,. . . , ... ...,,... -..�.„..��..wan.xz,wadwana:.a*x,4:a..a�..:,:t... .,:, . .,::. .,.,::.: . ., . 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