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HomeMy WebLinkAbout1620A (9) �, . . N� �� ` WORNERS'COMPENSATIOW�ECIARATlON �����'g� ppp�,�CAT`�.ON ��OR ElECTRICAL PERMiT a( � �I�ereby aHirm that I hpve o�certifimie of mnsent�o self _. msu�e, or a certificare of Workers'Compensation Insurance, COUNYY OF LOS ANGtlES . BUIIDING AND SAFETY oio cer tif,piead copy�hereof�Sec.3800.L C.} V�o'�Icy�d O S ' � Company FOR APPUCANT TO N��IN J09 Certified co y is hereb furnished. EnCH NO. FEE �+�DRE55 �'�.� p Y New Residential Bldgs.B Pools � 1 8 2-Fomii FI. f = S LOCALITY D\pI+M^�l Carlified copy is filed with�he couNy bvilding inspeo- Y��� f2� tion departmeni. Mul1i-lomily Sq.FL CROSS ST. p �� Doia ��-ft�A 1lcant 6 Resident�ai Swimming Pools OWNER OR Q�� PP FIRM NAME �� `3V� CERTIFICATE OF EXEMPT N FROM ORKERS' Ootlets:Ret__light_,_Sw._ ��� , COMPENSATtON INSURANCE nooaE55 Fi�s�2b (Tlyt soelion naad not bo complafad if Iho work involvod by Totot No. Additional CIiY ,� Tel.No.7l�(pZ ,� Ih�pannif i�for ona hundrad dollars(;100}or lo�s.) PIAN C EIX I cerfify �hai in the perfo/monce of the work fo�which�his _ . - nvPLICANt permit is �asued,I sholl not employ ony perwo in any manner soas to become subject fo the Workers'Compensation taws. li9hting Fixt�res firs�20 ADORE55 Totol No. p�������� CITY Tel.No. DaPo opplicon4 Fixed Appliances Not Over 1 HP pERMiT � NOTICE 1'O APPLICANT: If, ofler making this Certificate of qpPttUNi Exemption, you should become so6ject �o the Wo�kers' Range_Heater D W.� � - � _Dryer W.M.— ADARE55 . � Compensotion provisions of the Cobor Code you must forih- Oven ,�Cy,.� _ _ _ _ . - � - with comply �aeitb.such provn oru a this permir ahap be iop _FqU —,.W1i.---.-._� . - ----- - -� -� "- - _ - --� - - -- deemed revoked- .---. -.�--=---... }{� _fon _Other_ CITY- Tel.No. � - 1lCEN5E6 CONTRAtTORS DECLARATION ttcENSE OR p 1 hereby affirm thot I am licensed under prov�sions of Chap�e�9 �'�� —Room Air Cond. — REC,.NUMBfR � ��Ou•!1 r (commeneing wiEh Ssction�7006}of Division 3 of the Business power Apporutus 8 large Appliances DISTRICT NO. PROCESSED BV (L � and Professiona Code,and my license is in iull force and effect. �� Size 6 Type MP,KW,KYA,or KVAR C� � license N�mber �9 3�� Lic.C1oss�L�. Up�o i IncL FINAL 1^ � � i�� q_ ` Ovor t to 10 fntl. �A� � ' �� - VALIDATIOH � �s � Conrroctor�� C�i�"�'°�bate �'� Over 10 fo 50 Incl. _ 4 ❑ FINAL W � t om exempt urtder Sec. Over 50 fo 100 Irx. BY � � � 8.8P.C.for tbis reoson ��e��� z 4 Services,Swbd.,MCC 8 Panelboards � � ' �O�°' 0-2(10 Amp.Under 600 V : Signature '� 201.1000 Amp.Under 606 V � ' O Over 1000 Amp.ar Ove�600 V z� (��;Q p 1 : EFempt�on for Reg.Maint. �ect. � ' SIIVGLE FAMILY Temp.Power Pote 8 Appurlenonces � � �� � � � �2 � ! HOME OWNER-BUILDER DECIARATtON Sign with One Branth Circuit � a e 2 rJ.�Cj ' 1 bere6y affirm ibaf I am exempt fram the Controctor's Lice�se qddi�ional Sign Branch Circuits '� Law for the following reason (Section 7031.5, Business and �,„�, � • a.�'S..�:vr- � Vroiess�ons Code): � ❑ I,os owner of the properry,will do Ihe work and the Misc.ConduiR 6 Canducrors � structure i;not intended or offered For sale (Seclion Other�See Complete Fee Schedo�e)_ � ��'���R� � 7Q4d, B�siness and Professions Code). CONSTRUCTION LEN�ING AGENCY 1 hereby affirm that there is a conshuction lending agency for �he performonce of rhe work fo�which this permil is iuued PERMIT FEE (Su6-To�al) /�� �Sec.3097,Civ.C.}. PLAN CHECKING fEE Lendei s Name PERMIT ISSUING FEE IO lender's Address �� I cenify that I hove reod this application and sto�e tha�the iOTAI FEE obove information is corred.1 ogree ro comply with all County ordioonces and Sfine lows regoloting Electrical wiring,and hereby authorize representa�ives of this County to enter�pon the ahove-menfioned properfy for inspection purposes. SEE REVERSE POR EXPLANATORY LANGUAGE � �gnaWt � ee ��Dot� � 1 r � �=iao °� n " `�� � � T� oo�b I l I o...;� � pr #.°'' a � a� c a m a C �� � 0 3 o p o os m o c y c n-'" a � c.c � , � f a^ �o o�s L C4-=� °'-'c o l� am ov o p � ; ' .. � c C� • � p u� � : 0 .� �l''N.0 ! i ' U O � O pl•w C � O 0. j �:�p� C A Q � I � I . Z v Q � c" �>' £ N a c �v= �a �" � a m a f �y � � . 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