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HomeMy WebLinkAbout1759A (225) WORKERS'COMPENSATION DECLARATION 76A663 10�ei APPL1eqT�4iV FOR EL�CTRICAL PERMIT � I hereby affirm thal I have a cer�ificote of wnseN to self CE-806G ins�re,or a certiFicare ot Warkers'Gompensotion Insurance, � UNTY(SF COS ANGELES BUlLDING AND SAFETY or a c �hfied co � er f Sec 800,Lab.C) � ,1,� �t�t�"�`�b�o� P❑ol�icy o. Compony fOR APPLIGNt TO FIL[IN � ��E�� � 1 I Cer�ified�opy is hereby furnished. New Residential Bldgs. o,yls EACH NO. FEE � l 8 2-Famil S Pt. � s — S LOCALITY Certified copy is filed wilh�he mvnty bvildi�g inapeo K 4� �ion depariment. Multi-family Sq.Ft. ROS9 5T. p f1 � Residentio{Swimming PooVs OWNER OR Date � AppficaM Y �.V 9 G�i n FIRM NAME CERTIFtCATE OF fXEMPTION FROM WORKERS' OuNe1s:Rec_Light_Sw..�_ ��� COMPENSATION INSURANCE AO�RESS� First 20 (This s�dlow nwd nof b�comploted H the wotk inrolv�d by To�o�Na. .4dd�+ional C�TY Tel.No. 1he pormlf is for owo kuadr�d delhn(t108)ar f�t�.) PIAN CHECK �j� 1 certify that in�he perfamance of the work fw which�his aPPLICANT permit is issued,i sholl not employ any persan in ony manne� so ns to 6ecame aub�eU to the Worken'Compenso�ion iaws. U9h�ing Fia�ures first 20 ADQRE55 '-� 1 �(} `, „ Total No. �d�t`O`!°� CITY Tel.No. Date .�-�PC' '�pplicuM `•X�L�Y Fixed Appliances Not Over 1 HP pERAVT _ fy"'CE TO APPLICANT: If, after moking this Certificate of qpp��GqNT p �y �tion, yo� should become sub�ect to the Workers Ranye.�HealCr�Q.W....�..._ --.pensotion provisions of iFe La6or Code,yo�must forth- Oven _Dryer _W.M..— ADDRE wirb comply wirh soch provisions or �hia perm�t shaR be Top _PAU —W.H.— � . � deemrd revokad. Hood _Fan �Orher_ CITY � � G�,yp1y 1.No.('p af� LICENSED C6NTRACTORS DECLARATION UCFNSE OR n � Disp. —Room Air Cond. — REG.NUMBER ��- . ��Ou�l.`���} !hereby affwm ihar I om licensed urrcler provisiorn oi Chopter 9 �- (commencing with Secfion 7000�of Division 3 of�ha Business DISTRICT td0. PROCE BY 4 � ond R'ofessions Code,and m "cense i:in full force ond effect. Power Appomtos&Lorge Appliances Q� U ��.Lh� �l,�d � Size&Type HP,KW,KVA,or KVAR � 6 Lfcense Num6er���c.Class Up to 1 Ind. FINAL �� p Over 1 to 101nc1. DATE �l���J VALIDATION � �y Controcror � Date ,2`�'{'�•S j� � � ❑ Over I Q to 50 Inci. f�Nq� W I am exempt�nder Sec Over 50 to 100 Inc BY a tg O�er 100 Z 7 B.BP.C.fa�this reason � Dote: °�����es,Swbd.,MCC 8 Panel6oards � 9 , 0-2(q Amp.U�er 600 Y - I i�� r � Signoture 201-7000 Amp.Under 600 V � ^� � ❑ • Ove*1000 Amp.or Over 600 V ,. - � • � ' � Exemption for Reg.Mainl.Elecs. �� � SIDtGIE fAM{LY Temp.Power Pole 8 Appurtenantes � ' ' • " I HOAhE OWNER-BUILDER DECIARATION g�y�„V�th O�e&onch Circuit . - - - � - _ j 1� y aHirm thol i am enempi from the Convoctar'tLicanse pdditlonaf Sign Bronch Circuits � � � ��� Lcl.. ,r the foilowing reason(Sectian 7031.5, Business and � Protessions CodeJ: i .' i i— �"� � ❑ I,as owner of the p+operly,will do ihe work ond�he Misc.Condui�s 8 Conductors strucwre is not intended or of4ered fo�sale(Section Oihar(See Complele Fee Schedule)_ � 7044,Business and Professions Code�. . CONSTRUCTION LENDWG AGENCY � I hereby nffirm that there is a construNion lending agency for Ihe performance of the work{or which ihis permi�is fssued pERMIT fEE (Sub-Total) (Sec.3097.Civ.C.�. PLAN CHECIGING fEE Lender's Nome PERMIT ISSUING FEE ' lender's Address I cerGly fhat i have read ehis applimtion and srate ihat the TOTAL fEE t� a6ove infamaiion is cwrect.I ag�ee to comply with all Counry ordinances and State Iawz regulating Elecrrical wiring, ond hereby au�horiza representotives of this County to enter upon ihe above-memione preperty ior inspecuon pmposes. SEE REVERSE FOR EXPtANATORY I.ANGUAGE � l�l��� Signa�ure�irree Date t m w N � .� 'a �r �..c ¢s'O � . �o h-C y 6t b � 3_"�' a Q OQ'.b P r„� � n � �'� ..-.. . n MO �0 p in�O � O-O � D c s O n �'D a'C . �^ ,�' y O� C C�.Cy�s O t� Rp � j � O oOD� � � Omb� ON � �'�� 0� �� 4�� � V � �+ j�C i E y O C u ' �: N~ ��G �.�c � c z a � .. d o c H o c c � " o >N d L � � Q...,� �-0 [ o0�°b v° � 3 ' ' y ° � � o p . 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