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HomeMy WebLinkAbout1369A (7) � WORKERS'GOMPENSATIONDECLARA710N J6A6d3 �a,e� �� APPLICA'FION F4R ELECTRICAL PERMIT � I hereby affirm thar 1 have a cerrificare of conseni ro sel( �E�B�' insure,or o cerrf�cata of Worke.s'Corr�pensonon�nsu�o�ce, COUNTY OF LOS ANGELES BUIIDING AND SAFETY � or aCerNfied copy Ihereo!(Sec 3800,lob.C.) . P❑oilcy No. Company � fOR APPIICAM TO iLLl IN DDRE55�� .d Cenified copy is hereby furnished. New Residentiol Bldgs.8 Pools �CH NO. FEE S .. � 1 8 2-Famil IOCALITY � � �. Cerfified copy�s filed wirh iha couny build�ng inspec- Y�59•F�• b S � fion deportmenl. . Multi•family$q.F1. — NEAREST Residential Swimming Pao�s �j���R� Dote Applicant . FIR,41 NAME E1hS � . T�G CfRTIfICATE Of EXEMPTION FROM WORKERS� - Outlets:Rec�light__Sw._ ` �L � COMPENSATION INSVRANCE - a.00RE55 T (Thi�sreNon nNd noe b�eomplN�d ff eh�wo`k Inrolv�d by Totol No. Addil onal J CIiY C� tl� Tel.No.�� fM p�rmN 6 for on�Aundnd ddlon(;100)or I�s�.) plqN CHEIX• � � ( I ferlify rhol in the performo�ce of the work for which this � APPUCANi� - ��¢e t is issued,1 sholl noi employ any person in any manner s to become subjeU to the Workeri Compensotion Laws. Lighling Fixfwes First 20 AODRESS � �/ /� Addirionol �} ��• _� ..L� 7oto1 No. . QTY - Tel.No. Daie1 pplTe �S 1 Fixed Applfonces Not Over 1 HP pERr�ii NOTICE�iO APPLICANT: if, oher making ihis Cer�ificate of . ApP��CJNT �G , Exemption, you should beroma subject to rhe Workers' Ranga_Heaier_D.W._ . Campensation provisions o4 the Lobor Code,you musl fonh- Oven _Dryer _W.M.._ AODRE55 � ,.1"7- ith comply wi�h such provisions or �his permit shall be Top _fAU _W,H.— GTY ��, � Tel.No. 3 deemed revoked. � Hood _Fan. _Oihe�_ � � IICENSEO CONTRAC70R5 DECLARATION Ois _Room Air Cond. — liCEn'SE OR _ Class. I he�eby offirm fhal l om licensed under provision:of Chapter 9 P' REG.N�MeER `1 /Cl (commencing wirh Se<tion 7000)of Division 3 of ihe Business � �ISTRICT NO. P ED BY ond Professions Code,and my license is�n foll farce ond eHecl Power Apporolus 8 large Applionces � � , Size 8 Type HP,KW,KVA,or KVAft 0 License Number Lia Ciass �—�� � �p�Q����� � � FINAL � � V � Controc�~� Date '� /�' 3Y � Over 1 to IO lncl. �DATE - �����'fj� VALIDATION � OOver 10 ta 50 Incl. FINAL ~ � I am exempl under Sec O�cr 50 l0 100 Ina. BY W ' � � 8.8P.C.for this reason Over 100 . N . Sy�ivarSw�bd.'AAGC-iAc oord J , Z Dafe: . Z, r . � 0•200 Amp.llnder 600 V �� � Sig�a+ore �01-1060Amp.Un er V�/,�'7�] _ Over 1000 AmP.or Over 600 V " , ° ° ° �•� . � Ezemption far Reg.Moint E�eU. � . - � � ,� � S�NGLE FAMILY � ' `:)�:r� Temp.Power Pole&Appurtenonces i � HOME OWNER-BUILDER DECLARATION Sign with One Branch Cirwit s ,� - �.7`s I hereby offirm�hoi�am exemp�from the CoNroctor's License Addiiionol Sign 9ronch Circuits ' low fa�the following reoson(Sec�ion 7031.5,Business and � G-' I _-�G Professions Code): . "� ❑ t,as owner of the property,will do Ihe work and tha Misc Conduils 8 Condaclors - - strocture is noi inrended or offered(or sole(Settion Q�her(See Complete Fee Schedule)_ ► � 70ad,8usiness ond Professions Code). CONSTRUCTION IEN�ING AGENCY � .� 1 hereby oHirm ihat rhere is a construuion lending a9ency lor ' - the performonce of Ihe work for which this permft is f:sued PERMIT FfE � (Sub-So�al) . . (Sec.3097,Civ.C.). ' ,�i PLAN CHECKING FEE Lender'sNome��VU T T4P ,�n�O ' � `�_„_ _ ����r'�(�� �_ PERM17 ISSUING FEE . .. _ . � Lender i Addresr � � ^� I.cerrify rhor I hove read�his applicotion and srote rhaf the) TO7AL FEE , 3�.ds above informo�ion is correcr.I ogree ro comply witb oll County t�., � ordinances and Srore laws regulatin9 Electrical wiring,ond �ti'�A 9���� here6y aofhorize represeniofives of ihis Counly to eNer upan - " � the obove-men�ioned properry fo�i spection purposes. . SEE REVERSE fOR EXPLANATORY LANGUAGE � r �.�_� ,� 1 /1 �� , . . Signature o/ rminee Dare � c ! - ; - �aump �Vod . uos�a�s�yi�oi'J'd 8 8 . ' . , � . . . � ,�::t,_."� . .. :i.. , ' _. . .. .. •�ag.aapun idwexa wo��-- - . , .. _ . . 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