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HomeMy WebLinkAbout1774A WORKERS'COMPENSATION DEClARA710N 76Ae63 t0i81 qpp��CATION FOR ELECTRICAl. PERMIT ` � w� I here6y affirm�hat 1 have a cer�ificate of consen�to seR CE-806C �� �� insure,or a cerlificote of Workers'Compe�sa�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certifi w y thereof(Sec 3800,Lob.C.) P❑oHq No`.��ompany �/�/�US/ic-j/'F'L FOR A►►UCANT 70 FILL IN 1OB ' Certified co �s hereb f�rnished. EnCH NO. FEE A�IN2Eu �' py� Y fN/�� New Residentiol Bldgs.8 PPP Is�-�/ .—f'i,,,, �1 (� 1 8 Z-Fomil S Ft.� f = s LOCAUT � a�0 ��3 iy Certified mpy is filed with ihe coonty 6uifding inspec- Y• 4� dep rtment, Multi-fomily Sq.FI. CROSSSST. ResidentioV Swemming PooVs OWNER OR Dote�� � Applican FIRM NAME � CERTIFICATE Of EXEMPTION fROM WORKERS' Outlels:Rec_Light_Sw._ " � ��� /� COMPENSATION INSURANCE A�DRESS - . x, 7 I First 20 (Th{s a�ction nNd no1 b�complrF.d H th�work[moirad by 7otnl No. Addilional CIT n/a,qf��, Tel.No. � � j fhe prrmll Fs for ana hundnd dolkro(t100)or less.) PlAN CHECK � 1«rlify�ha�Yn Ihe performance of�fie work for whicb�hls APPIICANF � permir is iss�ed,I sholl no1 employ ony person in any manner so os m bemme aubject to�he Wahen'Compenmtion laws. LigMing Firtures First 20 AODRF55 Addilional Total No. CITY Tel.No. Date 6PP��ro^j Fixed Appliances Not Over 1 HP pERMIF .+�p � CE TO APPIICANT: If, nfter mpking this Cestificale of qpp���T � �ption, you should become su6jed ro tha Workers' Ronge_Healer_O.W._ �Compensotion provisions of Ihe Labor Code,you musl forlh- Oven _Dryer —W.M.— � ADDRE55 , v � �/�� with comply with such provisions or this permi� sholl be Top _FAU _W.H.— J, ,l /�� deemed re�oked. 1-iood _Fan _Other_ CITY /K J Tel.N . LICENSED CONTRAC70R5 OECLARATION uCENSE OR /�]..�� ,,e� �1 � Disp. ..,Room Air Cond. — REG.NUMBEH !/C/ � ��""��V i he(e6y oHfn„rhot t am licensed under provisions of Chapter 9 Q (commenNng with Section 700p)of Division 3 of the Business power Apporatvs 8 Lorge Applionces DISTRIC�NO. PROCESSED 8Y O � ond Profassians Code,and my licen5e is in full force and effe<t. < ��p,,j)�� Si:e 8 Type HP,KW,KVA,or KVAR � �Q`O n U License N�mber_���s��_lic.Gnss �� � UP fo I IncL FINAL '` � L O � � � OATE I VAUDATION V � �—�7 Over 1�0 10 Ind. y �`� I Gontroctore�`���� Date Over 10 to SQ ind. FINAL � � � 1 am exempt ur+der Sec. Over 5�ta I00 Irrc. BY N � B.BP.C.for this reoson Over IQO � Z � Services,Swbd.,MCC 8 Panelboa�ds � � �O�e1 0-200 Amp.Under 600 Y ZE Signature ZDI-)000 Amp.Under 600 V � aOver 1000 Amp.or Over 600 V z � / !,-;ti Ezemption for Reg.Maint.Eled- � � SWGLE FAMIIY Temp.Power Pole&Appurfenances � � � � �� HOME OWNER-BUILDER DECLARAFION 5� ��,,�ith One eranch Circuit i;� �by affirm rho�1 am exampt from�ha Conhaclor's License 9 � � 4'1 f-.","�� Law for the following reasan (Settion 7031.5, 8usiness ond Addioonal Sign Branch Circoits Professions Code): • e e j!„=,_?= ❑ I,as owner of ihe properly,will do�he work and the Misc.Conduits 8 Conducfors G9,22—: r. sirudure is not in�ended or offered far sale (Seciion Other(Sea Complete Fee Schedule)_ � 7044,Business and Profeszions Code). CONSTRUCTION LENDlNG AGENCV I hereby affirm�hat there is a construdion lending agency for � the performance of ihe work for which this permit is issued VERMIT FEE (Sub-Total) ,�Q (Sec 3097,Clv.C.j. PLAN CHECKING fEE lender's Name � PERMIT ISSUING PEE Lender's Address /_ p I certify iho�1 have read ihis application and state rho��he TOTAd FEE �!� O above intormatio�is corred.i agree to comply with all Counly ordinonces and S�ate lows regolating Eledrical wiring,ond • hereby authorixe representatives of this Couniy to enter upon the e-mentioned proper�y for�nspad�on p�rpo es. SEE REVERSE FOR EXPLANATORY LAN6UAGE ��� �'�s� � $ignoture of Perminee Da�e F � I m'a , � , �v ° ° �� � 1 +v c c, m 1 ` . v �t"'- �. m n y � �s' , 1 � � ° , � � � N N o_a� o` � av .� � 01 O Q y� � 1 S}_�'�� 1 : .L � d, m« .[] u d j V �''CO � 0+ r �n ., � o ; 6 m u�+ m s � =o ym � � a � ,` t �..�,�o NN °,c°' «. '� a os�- @ °cr•� ��a � �o3,Eodcv�v° N > sn c3 > ,: a,o ' t ' �'.m. c c c.'p i+ a+� �ec �° o p� c ° ,`o v o'O ° > 6 o N � , �` V 6 � � � o ° £ m o o�-��- ��u a ° E ��� c- , i G Q � � Q� fl- u G � O �' y �i G O c ,L S y1`u 6. :4 . 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