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HomeMy WebLinkAbout1752A " WORKERS'COMPENSATION DECLARATION 76A563 t0i61 qpp��CATfON FOR EL�CTRICAL PERMiT � f hereby affirm thm 1 hove a certifimte of cansent to self CE-BOtG • insure,or a certifiwre ot Workeri Compensatlo�I�surance, � � C�UNTY OF LOS ANGELES BUILDING ANO SAFETY � a�a�tifjed(jy�hg�eo�5�3800,Lob.C �) ,N ` ( 1 �„ I ❑ty No(� .�C'� om any FOR APPUCANT TO Flll 4N JOB � Certified to is hereb furnished. � EACH NO. FEE ADOkESS tn py y New Residential 81dgs.8.P yo�l' Q �pCq��TY � ❑ 4 8 2-famil Ft�(Sd�— f ' s � � � Certified topy is fited with the muniy 6vilding inaper Y'�' ,_ r�EAREST tion deportmen�. Mu�ti-family Sq.Ft. CRO55 5T. �-1`�l•� pplicant �������- ResidenliaV Swimming Poofs OWNER OR . Dafe A �, FIRM NAM CERTIfICASE Of EXEMPTION FROM WORKERS' Outlels:Rec_light_Sw._ N''41L COMPENSATIOhI�NSURANCE nD�RE55 Firsf 2(1 ` (TNI�totlion nNd no�la�compl�Nd H Ih�work inrolvad 6y Total No. Addilional CI Y Tel.No. � fh�p�rmit is for ona hundrod dellan(=100)or lep.) p�qN C� t�{� �4+ � I certify ihat in Ihe performance of the work ior which Ihts APPLICANT - parmit is issued,i shoit no�employ any person in any manner so os to become aubject to fhe Workers'Compensotiort tows. li9Ming FixWres Firet 20 ADORESS � Addilional f� �`� A Tofal Na. CITY Tel.No. f Date��`��� �pplicam � Fixed Applioncea Not Over 1 HP 4 "E TO APPLICANT: If, after making Ihis Certificate of PERM17 C ' E �ion, you :hould 6ewme subjed io the Workers' Ronge_Hepte�_.D.W.__._ AP�IK�NT � ����pensat�on provisions of the Lahn[Code,you must.fwth• Ovan _Dvyer ._W.M.— AODRE55 � �. with comply ith such provisions or this permif ahall be Top .—FAU —W.H.— r. „ � deemed revoked. Hood �fan _Other_ CITY 4 el.No. ���7 LICENSEO CONTRACTORS OECtARAT10N ���N�� t hereby affbm thai I am licensed under pravisions of Chapier 9 Disp. _Room Air Cond. — REG.NUMBER�� '��-� ��°�' '"�� F . (commancing with Section 7000)of Oivision 3 of the Business D15TRICT NO. PROCESSED 2 � ond Profess�ons Code,and my Gcense u in f�ik fdca and effeci. Power Appora�us 8 Lorge Applionces U � n ,� Si:e&Type HP,KW,KVA,o.KVAR � License Number � � Lic Ciass_.�S.�L� �P io�����, FINAF � � Over 1 ro 10 IncL �A� ��l/�g VALIDATION � Confroctor ����-1 Date `�`'Gg� Ove�10 to 50 Ind. . V DBWAL c.t �i r�.i i; a I am exempt under$ec. Over 50 to iD0 Inc N B.&P.C.for this reosan Over 100 : .. t �[ Z Services,Swbd.,MCC 8 Ponelboards � F ` ' �- ��'�` �ote: p_2pp qmp.Under 600 Y o ' � ,< x I Signature 201-7000 Amp.Under 600 V ❑ Over{000 Amp.or Over 60p V 1 ;. � . . .. � Exemption far Reg.Muint.Elect. + SINGLE FAMILY Temp.Power Pole&Appurienances i HOME OWNER-BUIIDER DECLARATlON Sign weth One 9ranch Circuit . 1 k �affirm ihot 1 om exempt from the Contractor s license qdditionol Sign Bmnch Cirwits La�. ,r 1he followinq reason(Section 7031.5,Business and Professio�s Code�: ❑ I,as owne�of Ihe property,wi�l do fhe work and the Misc.Cond�its 8 Conductors structure is not intended or offered for sole(Section Other(See Complete Fee Schedule)_ � 7044,Business arrd Professions Codej. CONSFRUCTION LENDING AGENCY 1 hereby oHirm that thera is o const.oc�ion lending ogency for the p¢rformance of the work for which this permit is iss�ed PERMIT FEE (Sub-Totol) (Sec.3097,Ci�.C.�. PtAN CHECKfNG fEE Lender's Name PERMIT ISSUING FEE r� lender's Address + � I cerlify thal I have read Ihis application and state ihat the TOTAL FEE � o6ove infa.moiion is correcf.I ag�ee ro comply with all County ordinances and State lows reguloting Electrlcol w�ring,ond he�eby oulhorize representatives of Ihis County to en�er upon ihe pbo�e-mentio roperty for inspecnon purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE �,� ���.�.,�� I Signalure of�e Daie . �_ . �� � ". i� +V� O`'� r �:�d L/-'.p d „ � C C.C, . �L '�' '- Q p- f ' O y O t: O D . .c � m� m ° u u'c 0 `' °' S�t ✓ � u� 6 �p.L1 m � > �+� tJ 'n-,OG '^ � ��^ ' -Q M L tl Q N p C a =� +� � ��9 � � « � C O _ ' O � ' �r- .3'C'm �� O��.c C Q � ? y r r m� d . � �„�. '1 . 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