HomeMy WebLinkAbout1648A WORKERS'COMPENSATION DEQARATION 7d46as i0/el qpp��CAT�IQN FOR-ELECTRICAL PERMIT �
I hereby affirm ihot{have a ceriificate of consent�o seli �E'�G � �
insure,or a�errificate of Workers'Compensation tnsurance, COUNTY OF LOS ANGELES BUILD{NG AN SAPETY
or a cej t�,i,f�i�d co y t r f( ec 3800 b.C.) p
7(�1��[� .��� , ')I� � 3 c�
Policy No: Company �"d � FOR APPLIUNT�TO FILL IH�� JOB
� Certified copy.is hereby f�rnished. _ _ . New Residential Bldgs.� Is EACH NO. FEE ADDRE55��'�� � _
�,Certified copy is filed with the co�nty building inspec- �8�-Family,Sq.Ft.� ; — a LOCAtITY
tio departme . �� � �-- - ���� Multi-family Sq.FL � — NEAREST �--- -----
�� .. Residential Swimming Pools CRQSSST.
� Data Applicnnt OWNER OR �
FIRM NAME
CERTIPICATE OF EXEMPTION FROM WORKERS' Ovtleh:Rec_LigM_Sw._ N'p'�� •
- '• COMPENSATION fNSURAN�E� � Fi�st 2� qDDRE55� �
� (Thit wction n�d nW ba tomplWod if Ma work inrol�ad by Total No. Additional G7Y /J• ' T I.No. a„Lv .
Ih�parmit is for on�hundnd dollon(5100)m INs.)
. 1 certify Thai in the performante vf fhe work for which this GL4N CHECK
. parmit is issued,I sholi not employ any parson in any manner APPLICAM
so as to k�ecome su6ject�o the Workers'Compensalion Laws. �i9hting Fixlures First 20 ADDRE55
Total No. Addilianal
�afe Applicant CITY Tel.No.
� � TICE TO APPLICANT: If, aftar making this fertificate of Fiaed Applionces Not Over 1 HP PERMIT
� Ran e Heoler,._D.W,_ . A��� � .
nption, you shouid become aobject to the VJorkers' 9. .—
�c.ompensation provisions of the�obor Code,you must forth- Qvan _Oryer _W.M.— AODRESS , a �'� G� s
i wFth tompty wi16 such provisiam.or fhis pertnif shalf be Top _FqU --W.H.—
deemed revaked. � -� � � Hood _Fan _Ofher_ CITY ��A�- Tel.No. :�
LICENSED GONTRACTORS DECIARAT{ON - � LIf�NSE OR /
�isp. Room Air Cond. ' __.,�� .�
1 hgreby affirm thal I om(icensed under prorisiorn of GVroptar 9 . - — . . .. .— � REG.NUMBER... CJ . � .
(commencing with Section 7000)of Division 3 of the Buainess power Apparatus&Large Appliances � DISTRICT NO. PROCESSEA
and Profassions Code,and my license is in tull force ond effecF. ) � �
r!1- 1�� .. .Size.&Ty{ee HP,K1N,.KyA,orlCVAR�
ticense Mum�be/r�lic.Class` r� Up to T Incl. FINAL �yf V
Controcror'�L 5� �� Date�'�_ Over 1 ta 10 Ind. DATE LI I ,,���LG VAUCATION � �
❑ Over 10 to 50 Incl. �� T F
I orn exCm f under Sec FtNAL
P �Over 50 to IOp Inc. BY �.n r, � '
B.B.P.C. for this reoson ��8��� J . Z �
Dafe: Services,Swbd.,MCC d Ponelboards �
0-200 Amp.Under 600 V
Sigoalure 201-1000 Amp.Under 600 V �
�❑ Over 1000 Amp,or Over 600 V
Exemp�ion for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole 6 Appurlenances � �
HOME OWNER-BUILDER DECLARATION Sign witkOne Branch Ctrc�it ' ^' �
�� ��� eby affirm ihat I am ezempt frpm the Contrgctw's Litense � � u�'�y�� � ,. �
...+for the following reoson(Sedion 703i�.5,Business artd - AddiliOnof�Sign$ranch Circuiis �- � � - -�� � "� -- � - � -_ �� � - � - �� ,'
� Professions Code): � �' ' � s `" '�
. ❑ . . . .. - ---..__ ... .. . ... . . . . . ..
Misc.Conduits 8 Conducrors ) a :�.�G '
' 1,as owner of the properry,will do the work and the � � �
i structure is not intended or offered for soie(Sectian Othec(See.Cemplete Fee Schedule�_ � �� � �
� � n • ' 'n��.T I
i 7044,Business and Professions Codej. � -- -- � - �- � 4�.." I
�� CON5TRUfTION L€N�ING AGENCY - .. . .. . . . -- . ... . _ . . _ - ' �' �� I
_ . :;;.. '3`--
� � I hereby oHirm that there is a construciion lending agarrcy for
�he performance of rhe work for which this permit is issued PERMIT FEE � � (Suh•Totai) �3 � --��� - �
� (Sec.3097,Civ.C.�. - -
� � PLAN CHECKING fEE � �
' Lender's Name �
F - � - -- DERMlT-ISSUlNG FE€ C)
` Lende�'s Address � �
( I certify thn�! have read this applimtion and stnte tho!the TOFAL FEE , _ . ._, ��,R�' �
...._....._.
� obove informatian is cwrect.1 agree to comply�wiih all Couny . „ � �� ����� �����-���-��-����� � � ��� �
ordinaoces and State law:regulating Electrimi wiring,ond _ .
hereby aurhorize representatives of this Counry ro enter upon �� � � - � � � ��� �-�-��-�- � � ��
�above-mentioned properfy for inspection purposes.
SEE REVERSE FOR EXPLANATORY IANGUAGE
-�' � —� �
ignaturg o Permiltee �ale
�
_... . . ���� ..
�
w S N.G ' w C .� V " l..G L C1� '_.
.ovi �„ e m � ,. m .N p a� � � u � p,t;a
003 ° N"° � �� m °c � co � �c.°c
� ^ ►m 0 m t ��.��C� m.�c o V �� p� � 0 � �
U � p� u [fl�° m O c � �+� m El'G 0 b G a p�-� .
Z � v � � c y `> � N a e u " s o�'" m s �,F E �=
O ` � a�m aO � ° °� ° -° ° � oa o `m" � N
Q E � � E =�._ �.".-'y:o h� -"'o � .. ' o a o
� `° $ " ' � P +s-o. � i' 'S . m -uV � o �d � u
Q o e `- � c�0 m E ` ; u '" � E 3 d c o
U amQ � o€ �i� co` E �'� o ' o,cs° �' da
o vrnm ° L ¢ oo"' a¢ a � ° N=aO.� �; c � �a
�j V C O � r�.0 L�V � W C L. C `"O O � � y Gl C� .
3 �. p,Y ,�M % O p y. a � t b-� ��
o � ouy Na3c °' o m�ao �� °„S� � ��,. �
� °•° Go � �`aaO " E� � LocN » ` 3iv° v� °
m ° v �,o „_' » d m �`o o 'c_ u m ° a° o °
W Ysm ° �cc` �p- mam m :. „-Oa °->�o_ o -o m
+- � � C d O Q � O L �+ • L C y
Z Q �E- u"'�� oa, � �� 3 ` d � 3a � � '
,o S n o m - � 3' o ��t; - '
� � am �.n--+-.00i�>-:ow �� o o � E Q ` :
� a 3 e ao a.e`o u= o�"y o m°° .°',.a„ o m� u � .° I
° ° c � mw ona °�.o '� �- E E o u �
�„ N �o w F t, �V �- "o u � d m.c� x U I
m c; a„ aoN�v? � o0b^-+'°Yec ` � � a. m c
� c e �. o � y c'a E
tu ; b�'� ooro � 000� ��o.co � �; o p °� p 3
_ ' GO � O O'EUN mv.l� V'O 3 3 • • O G _ m ❑ O
W r
� . �
H !
� I � �
N
�1.�
0 � � I
�
O �
` .
W
V
� W
y u' Y N lL
o � 3 z � g
0
a 3 g � a O
Q � _ [� *� � .
� o � � � � � Z p
� � � 3 LL ° � �. z
.�, 'J`