HomeMy WebLinkAboutNo Permit Number (2199)WORKERS'COMPENSATION DECLARATION 76A663 y i
CEEOcG 12-80) APPLKATIOl OR ELECTRICQL PERMIT
1 hereby aftirm that 1 have a certificate or consent to se(f COUNTY OF LOS AI1fGELES BUILDING AND SAFETY
insure,or a certificate ot Workers'Compensation Insurance,or
a certified copy thereoP(Sec.3600,Lab.CJ
FOR APPLICANT TO FILL IN JOB
rau-%0^ompany r r-a m,^
eacH NO. FEE AOORE55 LOt #70-1330 S. Red BTuffewResidential61dps.&Pools
Certified copy is hereby furnished. 1&2•Family,sv.Ft.—?929 — $ LOCALITY TR R
Multi-family Sq,Ft. ARE T I
Certified copy is filed with the county buitding inspection CROSS S7
Residential Swimming Poalsdepartment. OWNER OR
ne e 3-3 81 t t
FiRMNAME The Presle Com an
iApplicantr ',Q r r a-e F.1 p n t r'rtle[s:iiec.3Li9h[1_Sw._A«
First 20 AOORESS 46 0
CERT[FTCATE OF EXEMPT[ON FROM K'ORKERS'Total No. Additional CITY Tat No. 11COMPENSATION1NSl7RANCEPLANCHECKQI
APPLICANT V 7'l is section need not 6e completed if the work InvoWed 6
Lighting Fixtures First 20 ADCIRE55bythepexmitiaforonehundreddollus (5100)or tess.)Additional
TOtel Na._
CITY Tel No.
certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP
permit is issued,I shal[not employ any persort in any menner pERM{T II 1! tl C McGee &lectric I
so as ta 6ecome subject to the Workers'Compensation Laws. Range_Heater_D.W. APPLIGANT 6
Ov¢n _ryB_W.M._ APDRESS ,Q. aOX 2 8 8 6
Date AyplicanS Top _FAU._W.H.._
Hood_Fan _..Other_ Ct7V t No
NOTICE TO APPLICANT[f,after making this Certificate of Disp. _Aoom Air Cond._ IICENS '
Exemption, you sho¢Id become subject to the Workers' REG.NUMBER .533$Class .'-
Compeasation provisions ot fhe Labor Code,you must forth- poyver qpparetus&large Appliances DtSTA{CT NO. PR 5 E Bv i
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,ar KVAR
j
deemed revoked.
Up to 1 Incf. FINAL
Over i t0 10lnci. DATE
LICENSED CONTRACTORS DECLARAT[ON Over 10 to 50 Incl.
Z- VALIDATIElN
hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
8Y
9 (commencing with Section 7000)of Division 3 of the Busi- puer 100
ness and ikofessions Code,and my license is in futl force and c
effeet. Services
0•200 Amp.Under 6D0 V
License Number s c.Class 201-1000 Amp.Under 600 V i= ,7 6-+ k$
Contracior EleCt;y;CSlDate --8 Wert000Amp.orOrer800V
r. c s c r
HOME OWNER-BUILDER DECGARA7tOt3 Temp.Power Pole&Appurtenances
Sign with One Branch Circuit r s C "
hereby affam that I am exempt from the Contractor's qdditionat Sigo Branch Circuits
License Law for the foltowing reuon (Sectiun 7031.5,Busi-a ,,r'. " -
ness and Rofessions Code):
Misc.Conduits&Conductors
I, as owner oC[he property,will do the work and the Other(See CAmplete Fee Schedulel— 5 F '
stmcture is not intended or offered tor sale (Section
7044,Business and Professions Code).
CON57RUCTION LENDING ACENCY
hereby affirm that there is a conatruction lending egenty
for the performance of the work far which this Dermit is pERMIT FEE ISub-Totall 90 $issued(Sec.3099,Civ.C.).
ender's Namn pLAN CHECKING FEE (One-Fourth Permit Fee)
I.ender's Address PERMI7 ISSUtNG FEE 5
I certify that f have read this application and state that the TOTAL FEE gg 3
above information is corroc4 I agree to comply with nll County
ordinances and State laws regulating Etectrical wiring, and
hereby authorize represeneatives of this County to enter upon
the abave-m ntione erty for inspection purposes.SEE'REVERSE FOR EXPLANATORY LANGUAGE
3 3 81
Signaturp'f Permi Date
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