HomeMy WebLinkAbout1820A WORKERS'COMPENSATION DEQARATION ��`� ���8t qpp�iCP,TIOf�i FO� EL�CTRICr�L PERMIT �
I hereby affirm that I have�certifiwte of tonaenf fo self �-�G �
in:ure,or a certificate of Workers'Compensation Insurance, ���O2COUNTY OF LOS ANGELES BUk�ING AND SAFETY
o4 �ce,rjif�d_copy tQhereo �c.3800,eLo�b. ���y����
'F'b�y Klo. �� �ompony �+-��"t'�i�G l fOlt AKtICANT TO Fll Nl JOB )/tiy� �r [^J � 7'y.,v
� Certified copy is hereby fumished. EACH NO. FE /+DDRESS t V t 1GL) i./f 1
New Residentia�B�dgs.8�1�
� Certified copy is filed wilh fhe county building inspeo- �$2-Family,Sq.Ff. � — $ ��A��N �.�.L. •
lion department, • Multi-family Sq.FL — NEAREST ,
�� � ��� �'��-fr� Residential Swimming Pools CROSSSi.
Date�Applicont�__ �-�-'�, ` OWNER OR (� ,^�,�, ' „ L O
FIRM NAME t'fJ 1"k7� f [iIG�T� �
CERTIFICATE OF EXEMPTION FROM WORKERS' O��lars:Rec_Light_Sw._ h O � � C! � !M '
COMVENSATION INSURANCE qo��RE55G Jr LW ;
First 20
[This�cfion n�d not bo comp{ated 1{fhe wo�k lnrolwd by Total No. Additional CITY��Q�.Y'�� Tel.N �
th�p�rmff i�4or on�hundred dollars{5100)or ku.j �
PLAN CHECK -
I certify rhar in the performance of the work for which this PPLICAM
permir is issuad,1 shall not employ any penon in any manner
so as�o become subject ro rhe Workers'�Compennation laws. ligMing Pixrures Fi.st 20 ADDRE55
� 7ota!No. Additional
Oate oppiicont CITY Tel.No.
NOTICE TD APFIICANT: If, affer making lhis Certificate of Fixed Appliances Not Over i HP PERMIT ��i� L}a„�,_
Eaemption, you shoold 6ecome subject �o-fhe'Workers' Range_Heafer_D.W. — APPIICANT -C.fC6-r� r- �G
Compensa�ion provisions af 1he to6w�Cade,�you must forth- Qven _Dryer _W.M._ ADDRE55 S�—G� e•
with comply with such provisions ar rhis permii shall be Top —FAU —W.H.—
deemed revoked. CITY � $��.e f�
Hood —Fan _Other— �1 1r� Tel.N
LICENSED CONTRACTORS DECtARATION LICENSE OR Q�y�
I hereby offirm thar V am Vicensed vmfer provtsiom of Chapter 9 �isp. _Room Air Cond. — REG.NUMeFR �CJL�-f� �����''o
(commencing with Section 7000�of Division 3 of the Buslness Power Apparatus&Large Appfiances DISTRICT NO. PR SSED BY
and P/ofessions Code,and my license is in full force and effect. �`�,' Y �
/� Q Size 8 Type HP,KW,KVA,o.KVAR ��i�l� �" t
License Number `f�C����Lic.Class —�� Up to I Intl. FINAL V �
�p �-( p Over i to 101nd. 'j� — �Q . � VAUDATION
Controctor�'� 1`-- C�'e�- Oo�e p��� DATE Y � O
� � Over 10 ro 50 Incl. F- �
FINAL
I om exempt vnder Se[. Orer 50 to 100 Inc. BY W
8.8P.C.for this reawn Over 100 y �
Da�e: �����es,Swbd.,MCC 8 Panelboards � �
Q-200 Amp.Under 600 V � (
Signature 2p1-t000 Amp.Under 600 V �
Over 1000 Amp.or Qver 600 V
� Exemption for Reg.Main�.Elec�. . �
SINGCE FAMIIY . Temp.Power Pole&Appurtenances N
HOME OWNER-BNL�ER DECLARATION r�" • o ' •�
Sign wilh One Branch Circuit
i hereby affirm thm I am exempt from the Con�rador's Litente Additionol Sign Branch Circuits � . ��r � ''
Low for the following reason(Seclion 703L5, Bvsiness and � - ` - �� • �
Professions Code}: - . 5 f_
❑ I,as owncr of the property,will do the.work and the Misc Conduits 8 Condutlors ` ' `•� �� � + --
structure is nol intended or offered for sale(Section ��her($ae Complate Fee Schedule)_ � ����,._�,z,
7044,Business and Professions Code). .
CONSTRUCTION LENDING AGENCY . �
I hereby offirm that there is o consiruction lending agency for
the performance of the work for which this pe�mil is issued pERM1T FEE (S�b-Total�
(Sec.3097.Giv.C.).
PLAN CHECKING FEE _
Lender's Name � /Q
PERMIT ISSUING FE€
Lender's Address
I certify that I hove read this applicotion and stale that Ihe T�TA�FEE ��/
obove informa�ion is correct.I agree to comply with all County , �
ordinances and State laws regulating Electrical wiring,and
hareby aurhorize representatives of this County to enter upon
the„abn��entioned properr�io�p��'� SEE REVERSE FOR EXPLANATORY IAMGUAGE �
/// c.{i
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Signoture of Permittee Dafe 1
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