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HomeMy WebLinkAbout1071A (7) WORKERS'COb1PENSAT[ONDECLARATION 76A663 �pp��CATlON �OR ELECTRICAL PE�MIT �j' CE-906G 12�80) t hereby at'tirm that [ have a ceitificate of consent to se�f COUNTY OF LOS ANGELES BUILQING AN�SAFETY �j lnsure,or a certificate of W�rkers'Compensation Insurance,or a cerlified cop thereof(S`Evc 73800,Lab.C.) .� Yc�}�i,�Z�C�5 FOR APPLICANT TO FILL IN ,Ipg Pany New Residential Bldgs.&Pools EACH NO. FEE AODRESS � � Certified cnpy is hereby furnished. 1&2-Family,Sq.FL $ — �' LOCALITY Multi-falnily Sq.Ft. NEAflEST � Certified copy is filed with the county building inapection CROSS ST department. Residential Swimming Pools OwNER OR ��,���ijr! FIRM NAME llateJi.�][_LL.�plicant F putleis:Fe�Light_Sw._ O MAtL ��� � '( � Pirst 20 A00 CERTIFICATE OF'EAEMNTlON FROM��p�;1�� Total No.� Addinonal CITY ei o. COMPENSATION[NSURANCE PLAN a � (This section need not be completed if the woxk involved APPLICANT � by the petmit is for one hundred s ($IDO) or less.) Lighting Fixtures First 20 U Additionai AODRE55 Tate!No. � 1 certify that in the perform�� nf the work for which this Fixed Appliances Not Over 1 HP CITv Tei � permit is issued,I ahail n mploy any person in eny manner PERM� so as to become sub' to the Workers'Compensation Lutivs. Range_Heater D.W., APP ICA W � Oven �Dryer_W.M._ AO�RES � � � Da[e Applicant Top _FAU _W.H.._ . _ � Hood—Fan _Other_ CITY T Na. NO'I E TO�+PPLICANi:[f,after making this Certificate of Disp. _Room Air Cand,_ LICE O . Exemption, you should berome subject to the Workers' REG.NUM E lass � Compensation provisions of the Labor Code,you musi forth- power Apparatus&Large Apptiances D�STAICF NO. PROCE S o Bv with comply with such provisiona or this permit shatf be g�Ze&Type HP,KW,KVA,ar KVA /� ; deemed revoked. `�,1 aV�,�._. � Up to 7 Incl. FINAL O�er 7 tD 701nC1. DATE G LICENSED CONTRACTONS DECLARAT[ON Over 10 to 50 Incl. � ` ��` o Z- VALIDAFION 1 hereby aff'um that I am Iicensed under prnvisions of Chapter Over 50 to 1D0 Inc. FINAL - � 9 (wmmencing with Section 7000)of Division 3 of the Busi- Over 100 e ness and Professions Code,and my license is in fuli force and effect. Services - rIy 0-200 Amp.Under 600 V � � License mbe(ai.p�L���Lic.Class / 201•1000 Amp.Under 600 V Contr (��_�����j L Date � Over 1000 Amp.or Over 60Q V . l, HOME OWNER-BUILDER DtiCLARATION Temp.Power Pole&Appurtenances . 7 hereby affum that t am exempt from the Cuntractor's Sign with One 8ranch Circuit License I.aw fur the following reason (Section 703L5,Busi- Additional Sign 8rench Circuits ness and Professions Code): Misc.Conduits&Cnnductors � t, as owner of the property,will do the work and the Other 1See Complete Fee Schedule)— structure is not intended or offered for sale (Section �� Q�� A 7044,Business and Professions Code). CONSTRUCTION LENDING A(3F.NCY .I hereby aff'um that there is u construc' lending egency - #�� +_* ��� for the performance uf the work f hich this permit is pERMIT FEE ISu6-Total) ' #� � � � i� issued(Sec.3097,Civ.C.). . Lender's Name PLAN CHECKING FEE (O�e•Fourth Permit Pee) � • •2�3 3� Lender's Ad PERMIT ISSUING FEE !� �2�3 O�x,. I ceriify thet 1 have read this npp2ication and state that the TOTAL PEE � �2� $��„$' above information is correct.1 a ee to comply with all Cvunty ordimnces and State luws lat3ng Electrical wiring, und he aut onz r nt es of this County to enter�pon e ove-me io� r y for inspectinn purposes. SEE-REVERSE FOR ERYLANqTOBY LANGUAGE �gnati e of •1 � e � at�'� ! , � . �_ � \ � , u qi ' y^- � Gj. � ..L�'�'�•'^C. �' v, .. N',?C "'G�a-.� i, - f � et �' '..' Z«•�' �r {-� � :. _ `~C� G N ,... a. �'y, c ` ' V - S. .:: c; �.�i �i^ = :y c�,'v � `' , . . . hr5 "; �_ <: ' ` , , �O '- C +-.... p H'� c.• r � . �i fa `� .L, -- � '�. ' � �' �`�J .... 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