HomeMy WebLinkAbout0506A � WORKERS'COMVENSATIONDECLARATION �e�� io�e� APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm �ho�I have a ceriifimte of consenl to self �'�� � .
insure,or a cerrificoie of Workers'Compensotion Ins ante, COUNTY OF LO$ANGELES BUILDING AND SAFETY
�o certifiad��cQo/py t�he/r/ep f(Sec.3800 .)
��.P�oli[y No._�N/V_,�Compon � FOR APPUGNI TO FllL IN !OB
Certified copy is hereby furnished. New Residential Bldgs.&Pools FACH NO. FEE �R� �, d
-�erfified c is filed wilh the count buildin ins - LOCALITY �
o0Y Y 9� Pe�- 1&2-FamilY,SG.Ft. s — s �,Q�
NEAREST
tion eporl em. -� _� Muhi-familySq.FL CRp555T. /j
' � � Residential Swimming Pools A,.
�pole �`� APPlicanl � � FIRMENAME L.!!
� CERTI ICAiE OF E%EMPiION FROM WORKERS' Outlets:Rx—ligh�_Sw._ �"w'�� � �j
� - COMPENSATION INSURANCE A��u
7h1���clion nNd nof b�eom �eMd I!th�work involv�d b first 20
P � Tolal No. Additional� CITY Tel.No.
he permit k(or ons hundnd dallen(=100)or lass.) �
'certify Ihat in�he performaace of the work fw�whith Ihis qp�p�KjpjTK �
�ermit is iuued,I shall not employ ony person in any mpnner- � ^
o as�o become subject io the Workrs'Compensalion Laws. Lighting Fi�.tures Fire�20 ADDRESS � 6�r
�� - Total No. �+dditionol -
5te epplicant - � CITY �r�— Tel.Mo. �,.t�y(,
OTICE TO APPLICANT: If, after making this Certificate of FiKed Applion[es Nol Over 1 HP - PERMIT �
emption, you should bacome subject lo the Workeri . Range_HeaMr_D.W._ AVttIUNT
�mpenso�ion provisions of�he Labor Code,yo�m�st forth- Oven _Dryer _W.M._ ADDRESS
fh comply wilh Such provision5 or �his permit sFall be Top _FAU —W.H.—
emed revoked.- � CITY Tel.No. �
IICENSED CONTRACTORS DECIARATiON Hood _Fon _Othar_
Dtsp. —Room Air�Coad. — ��N�� 'I p Class
aeby affirm tFwt I am licensed under povisions of Choplar 9 ���1�ER O7�y'`�� � .
mmancing wiih SeUion 7000)of Division 3 of iha Busi�ess DISTRICT NO. PROCE BY
1 Profeuions Code,and my license is in full fwce and effe�y - Powe�Appara�us 8 La�ge Appliances �� . Yy
�y /J��� Size B Type HP,KW,KVA,or KVAR� �h�Q 0
mse Number r II lit.Closs��_ � � Up to 1 Ind. - FINAL A ./ . . V
� � . Over 1 to l0 1ntl. DA� `/�7/�`�' VALIDATION� �
� arotlor ,� Date p3 Ovar 10 to 50 Ind. - �
FINAL
, I om exemp�under Set. � Over 50 to 100�nc. BY �
��. B.SP.C.for this reason . �e��� y
Services,Swbd.,MCC 8 Ponelboords � . � � Z
�O1e' 0-Z00 Amp.Under 600 V
�� Signolu�e 201-1000 Amp.Undar 600 V .
Over 1000 Amp.or Over 600 V
�'Ezemption for Reg.NainL EIeU. - � � - �
SINGIE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One�&anch Circuit � �
�by offirm that I am exemp�from Ihe Conlraclor's license Addi!ionvl Sign Branch Circuils
�or the following reason(Section 7031.5,Business and � ��'L1 S Q S I1
ssions Code�: � . � � � I
Miu.Conduih 8 Conduclws - -" -- - #"�� � �'�2 - �
I,as owner oF the property,will do the work and the . �
struc�ure is nof intended or oHered for wle(Section -- aher(See Complete Fx Schedule)_ ► . _ .�.�:�4 Q 5 0
7044,Business'and Profassions Code). - .
� CONSTRUCTION LENDING AGENCY _ •.� •4 Q 5 0�
Sy affirm thoi there is a const�uction lending agancy for �2� 3�8 3
�rformance of ihe work for which this permit is issued PERMIT FEE � (Sub•To�el) �
1097.Civ.C.). . .
� PLAN CHECKING FEE � � � - � . , .
's Nome � � - .
PERMIT ISSUING FEE . �.
�'s Address� � - ' �
y Ihot I have read this applimtion and stole thol the - TOTAL FEE � -
informotion is correct.I ogree to comply wilh all County �
xes and S�ate laws�egulaiing Elecvical wiring,ond � �
�ihorize repre o�ives of fhis County to enter upon � � � � � �� ' �
• antionad rty for inspection urpos . SEE REVERSE FOR EXPLANATORY LANGUAGE
e of Permi Da�
h . . , . : . .. .. . . -
. . � � _. � _.
J > )
. � � . , .
i -. _
_ 4 . � ' , �' .. .
� ,
(. .
�.'� l . " ` c ,
� � . • ' i
�- i .• fi' ^ . ' . .
� �� � �'
i � _ .
� � Z �+ C � _ � �o
r f O z � � � A O o � •
• � ' N � � � Z � � V '.
: � n A � � _ .N a r .
n � o �
. . � � -Ci '� C7 � A .
- �_ � . O � �O c, p � ...
H � � C � � �D
. .r _ � v ~ 7AC O N
, o
�
" A
. � . 1.
C
� � '_ y
' • O m
]
T
N .
�
Z
, �
C
_.. A ,
. - rn �•.. ;
. ' 1
p o [a — . �'o -� SFFp'inT 4^ :�aN �nr�3.00-� �,�—
� po :o., .:' F� o �-. 00 . °� w� o � oqc � ocn"T -
� m b -',3 �'a.� o � xoNn ; n� �- � � P. mo � >> o _.
� '� n .o �•,� � a�.o-=.,� ❑w i,��- o n «b ;N o .
. x" ','a°'° �a = o A� --,° �m o' ^ a o-N ° o-
- . .� o �. 3 o w aa �.c' i�^„o�c o a�o ° o�q n o�
o �3 Q� ,
. -. ' °-� ' T'" o mm °o� � m`'c�SN i° � ' .�'^..
v �
' ��° 3 � �. � o w N O . S�c m O�.^N�,� m.� _ O
a _;;
, �- � '� F H m o F e o 7...�� s`m a 3 0 0 3 z
; � � o �pma`�3oN o �a° ° O.: wTc ' � so �
" Q ' �.< ao m° H Q ' � =� � o��^. ° � -••�,°� w o » �
ti .tn o c� F , a< o �o ,� ` 3 _ .��-m � � o o —
- . o ,.n � • N m � Q� T b a o o Cu o N � o p C
. , . � �.n j_So au� p' b�O O p ] ��p C �' 3 r
� : . . ' . .�tD � m� �,p O Qb ; � o.x 'W-•ti S�,C O f (f d
` ' a c� ►c °� �Q� o o ' 3 °,acv o P.��� �°
� � - . �.a� ip� 7'7 0`C p` D��^ 3 Q j b s� � � , O ..� 3 d ,
• � . N ] A O 7 O N fJ�` O �`C 7'C ; O � O Q j D� :(� . . . .
C'
. . '' �n '�� c'b � � Q a 4' � a O o �^S� � ,n o o A
� ' °.bti °,m o' ao q �-c '^ � o x» 3 • � 3 D
N p � � m s� a p o p ti,o o � p.b o,.b� �
o in
. . • .°to 3 r�m o i �o s �.n °a n 'N^ 3 c � � � �'O, � �
� �� p�S o o O � 0 2 7 � �"tJ 2 � C O � z -
- �T= �. � o� ° � f a a� o' o .ao o � .
� _4� w o ° c° v+T ' � a°�'�
- �-� . ti o � o �ro 3 �
,� . � a v ' �av .�^. a o �,'" o o F W o'
n,3.00 � � � � . oao ° ,��. �.° � �. o'
a o �-�c a a�. � � ".' �-ro o' o �-�.u� N