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HomeMy WebLinkAbout1789A J �. � � � WDRKERS'COMPENSATION DECLARATION 7M663 IOi81 �pp11eqTION FOR ELECTRiCA1 PERM /�/ I here6y affirm thor I ha�e a cerUficate of consen�fo self �E"�� ��J _ in:�re,or o certificote of Workers'Compensa��on Insurance, ��V�{TY OF LOS ANGELES BUILDING AND SAFETY�I T� or o ceriifi d copy thereof(Sec.3800,Lab.C.) '�+ P�olicy No`�.,/��'�'�3Company'N�S7n1� FOR APPLI[ANT TO iltt IN qppRE55 � S. P_ Certified copy is hereby furnished. /N� New Residentiol Bldgs.&P o EACH NO. FEE � Cenified copy is 4iled with the county boildiag inspec- 1 8 2-Family,Sq.F�. f — E IOCALITY a / 3� eporl ent. �/J Multi-family Sq.Ft. — NEaRESt D /�'��11 Res�deMio4 Swimming Pools OW ER OR Date �AppIF[on '�— `� ., FIRM NAAAE CERTIPIG4IE OF EXEMPTION FROM WORKERS' Outleh:Ret_Li9h1_Sw._ ��� COMPENSATION INSURANCE ADDRESS • JC ��a This wclion nwd ao16�eom I�Nd iF fh�work Invotrvd b First 20 , ( P Y Total No. Additiana! �TY vr,�a- 9/7��, Te�.Na. 7—ry�S ��. ►ho permlf i�fer o�ro kuadrod ddlen(f100)or ian.) '� I certif tha�in the 4ormance of t6a work ior which this PIAN CHECK 1 y pe� APPLICANT I permit is iswed,I ahall no�empby ony person in ony monner so as to become subjecl to the Workers'Companm�ion lows. Lighting Fixtures First 20 AOORE55 Additional Total No. CITY Tel.No. Date opplicant Fixed Appliances Not Over 1 NP pE�7 � �� E IOTICE TO APPUCANT: If, after moking this Ce��ifimte of qpp���T `��C ._'��,7 . ■emption, you should become subject io the Workers Range_Heater_D.W._ Compenmtiaa provisfons of�he tabor Code,you musf forth- Oven _Dryer ._W.M.— ADDRESS .�_ ��x �/d with comply witb svch pravisions or ihis permir shatl be Top —FAU -_W.H.— � deemed.evoked. CITY�� �� /7(��Tel.Nos � Hood _Fan _Other_ UCENSED CONTRACTORS DECIARATION UCENSE OR p I hereby oHirm fha�!om licensed under pravisians of Chapler 9 �isp. ..._ Room Afr Cond. — REG.nIUMeEft lJ�3 ��O �� � (wmmencing with Seclion 7000)of Division 3 of the 8usiness DISTRICT NO. PROCESSED BY a � Power Apparatus&Lorge Appliances ond Professions Code,and my license is in full force and effact � � /�/+.� „p� r`U Size 8 Type HP,KW,KVA,or KVAR � h V License Number t�lF'�ld�S Lic.Class 4- Up to 1 Incl. FINAL � � Conirocior�" T-Tl��U/� Date �� �er 1 to 101nc1. DATE 7�3�.�y VALIDATION O � � 0 � Over 10 to 50 inrl. FINAL W � I om eaemp�under Sec. Over 50 to 100 Inc BY � f 6.8P.C.for 1hi5�eoson Over 10p z = Da�e: Services,Swbd.,MCC 8 Panel6oards � 0-200 Amp.Under 600 Y Signotura 201-1000 Amp.Under 600 V ` � !�''��, OOver i p00 AmP.o�Over 600 Y �: • • • s c` Exemption for Reg.MainL Elecf. StNGLE iAMIIY Temp.Power Pole 8 Apporrenonces � ° `4�� �r- . HOME OWNER-BUIIDER DECLARATION . $ign with One Brarrch Cirtult _ � �ereby affitm thof I am eaempt from the Confroctar's License qddi�ionol Sign Branch Circ�its i � " � �- "� �ow for the following reason(Section 7031.5, Business ond ` , . Professians Code)� CI�.c�`�t:C � ❑ I,as owner of the o r�, wili do the work and the Misc.Conduits 8 ConduUors P� � Y Other(See Complete Fae Schedule)_ � siructure iz not intended or of{ered fw sale(Sedion • 7041,8usiness and Professions Code�. � CONSTRUCTION LENDING AGENCY � I hereby affirm ihot ihere is o construcrian lending ogency tor the performance of ihe work for which this permil is issued pERM1T FEE (Sub-Toral) i (Sec.3097,Civ.C.). R PIAN CHEGKING FEE � lender's Name PERMIT ISSU�NG FEE O Lender's Address I certify thm I have reod�his appfication and state�hat ihe TOTAL FEE �� � above information is correc�.t agree io comply with all Co�nty ordinances and State laws regvlaling Elecrricol wi(�ng, ond hereby authorize reprasentatives of thit County to eNer upon the ob e-mentionad properly for inspection es. � -�^�,� ���� SEE REVERSE FOR EXPLANA70RY LANGUAGE Signafure of Vermitte�,/' Daie .o�UN4 ��`+ .` o' � a `uco �� � `� ' ' e 3 Q ' �v c � m „ °i� � k '' .�'E p b o ��.c � o .c o V � °v u� w d J O C� m Q b C C�Q O „ � 3 N-C O T'' C-0...1.0 I I ' m�t� i1 fl C � m 0.� I � ' 7 a, i' 4 y C n `} � ,� O C .T'i r u0i� m.�C m � � �m I . . O ~ N" > 4�n 4 fi V � p U� p .D O b � � > i t' O w � o � u'�. �� , ,� � r A o o b o y� i�o ( ! . c a ti. � .: � � � � oAo^m � > '' � 3mu� onE � `poN i W ` m � ?� aFY� �.c� c � � �'� o ° r.c.°c � � a � � � � y a�v ° � m` e p' aQ �� u a N>�a � , o`a k. � � � �. 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