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� �
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