HomeMy WebLinkAbout1123 FLINTLOCK RD ' WORKERS'COMPENSATIONDECLARATION ��� �o�B� qpp��CATION FOR ELECTRICAL PERMIT � �
' I hereby affirm ihat I have a ceriificale of consent ro self CE�s06G
insure,o�a ce�uficate of Worke�i Compensa�ion Inw�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certH' o y thereo Sx.3800,La .C.)
� Policy� ��' mpony � iOR A/PLICANT TO Flll IN � qppRESS I NR
erlifiad copy is hereby furnished. . New ResideNfal Bldgs.8 Pools EACM NO. FEE
, � 1&2•Famil FL S — 5 LOCALI7Y
Canified copy fs filed with the cauny building inspet- Y•59•
. tion department. � MuNi•family$q.Ft. — mEAREST
. � � Residenlial Swimming Pools - CROSS ST.
Date Applimnl OWNER OR
FIRM NAME
� CERTIFlCATE OF EXEMPTION FROM WORKERS'` Oullels:Rec_Light_$w.__ '�'A��
. COMiENSATION INSURANCE -� ADDRE55
ta�Mfon nod not M com I.t.d if fh.�work ln.olv�d b Pirst 20
� � P Y Total No. CITY Tel.No. _
th�p�rmlf is for ona hundrad dollan(S100J or lass.) Additional
1 cerlify that in the performoace�of the work for which�his APPLICANTK
� parmil is issuad,I sholl not employ any person in ony manner
so as lo becoma su6ject to�he Wwkers'Compensaiion Laws. li9hiing Fiztures Fiisl 20 ADDRESS �v
. �. . .. Toial No. Additional
Dote °PPlicant . CITY� ����f"J,�,f�c, Tel.Na.s �G
� NOTICE TO APPLICANT: If, afler moking ihis Ce��ifita�e of F'xed Appliances Not Over 1 HP qpp�j��p,NT
� Ezemp�ion, you should become s�bject to �he Workers' . Ronge_Heater_D.W._
Compensation provisions of the Lobor Code,yoo musi forth- Oven —Dryer _W.M.— ADDRE55
with comply with such provisions or Ihis parmit shall be Top _FAU —W.H.=
deemed revoked. . , Hood —Fan _Other_ CITY� � Tel.No.
LICENSED CONTRACTORS�DECLARATION LICENSE OR
I hereby affirm Ihol I om�iceased under p�ovisions of Chapter 9 DiSp. _RooRt Air COn[J. — REG.NUMBER Class.
� (commencing with Saction 7000)of Oivision 3 of the Business DISTRICT NO. PROCESSE BY
and Profeasions Code,oad my license is in full force and effett. - Powar,Apporotus 8 large Appliantes . . t� �
? '` Size 8 Type HP,KW,KVA,ar KVAR Q
License Nombar.J��s� Lia Class " f�T � � Up l0 1 Ind.� FINAL � '� ff� V
��"�� (��,y�J /��r�? Over I to 101nd. DA� �/ VAUDATION . O
ConiraUorGlrsCT�se�—(rS�Dore Over 10 to 50 Ind. FINAL V
❑ " .
I am exempt under Sec. Over 50 to 100 Inc. BY , �+
8.8P.C.for this reason �Ve��� 2
Dale: - Servites,Swbd.,MCC 8 Panelboards ,' - -� - � - - �
0-'!W Amp.Under 6W V
Signature 201-1000 Amp.Under 600 V � .
❑ , . Over 1000 Amp.or Over 600 V .
Exemp�ion for Reg.MainL Elect.
SINGIE FAMIIY Temp.Power Pole 8 Appurtenances .
� HOME OWNER-BUILDER pECLARATION Sign with One 8ranch Circuil
1 hereby affirm Ihot I om eaempt fiom the Controctor's License qddilional Sign B�o�ch Circuils �
1pw(or Ihe following reason(Settion 7031.5,Business and � ��]S 3.�F
Professions Code): . .
❑ I,as owner of the property,will do ihe work and ihe Misc.Gonduiis 8 Conductois ' - -- �• • . .•2
srructure is not intended or offared for sale(Section Other(See Complele Fee Schedule)_ �
� • • 1 �.50
, 7044,Business and Profassions Code). �
CONSTRUCTION IENDING AGENCY ' ' - • • •� C,Jr O c�.-
I hereby oifirm that Ihere is a consfrutlion lending agency for �
the perlormance of the work for which this parmit is issued PERMIT FEE � (Sub-Total) � - �O Z O S—H.�i
' (Sec.3097,Civ.C.).
� � � PIAN CHECKING FEE - � � - � - �
Lender's Name
PERMIi ISSUING fEE . � . Q .
Lender's Address
I cerfify fhat I have read Ihis applitalion and s�ate fha��he TOTAL FEE
obove information is mrreU.I agree to comply wilh oll Counly .
ordinantes and Sta�e laws regulating Elattrical wiring,and � , . -
, hereby outhorize represeMotives of�his Couny to enter upon � ' � -'
Ihe ob e entio perfy for inspeUion purposas. - .
� �-- SEE REVERSE FOR EXPtANATORY IANGUAGE � . -�
a�.� 7 5-83
ignaW� Permiflee Date - '
� ' APPROVALS- - DATE -- . . . - ' � J"� '=�`''-OWNER-BUIEDER DE[LAP.ATION_"
�• - SIGNATURE
� . TEMP.POWER POIE �� � � � � � I horo6y affirm Ihai I am ezempl from the Contracfor's
.- - - . ... . � � ' �Litense Law for tho following reason ($ocrya❑ 7031.5,
UNDERSLABWORK. � . . . � BusfneesandProfcsslonsCode):Anyclfyortouniywfifch
, ROUGH CONDUIT - ' � � - , reqWres a permlt fo construct altor,Improve,domolish,
� . �or repalr ony sfr�cfure,prfor�o I�s Iss�ance,afso re-
� � � WIRING � qulresfheappftconfforsvchpermlffofifeas�gnedstale-
'"� �� :'�' � � �� FIXTURES � � - . . ' . . . ment Ihat ha b ficeneedpursuonl lo the provlsfons of 1he
, , Contraclori Lfcensa Law(CFapfer 9(commondng wrrh
' ' " � POWER AUTHORIZED Sectlon 7000)o/Divislon 3 of�he 8uslness and Profes-
� � , stani Codc)or fhat hc Is oxempt Ifierclrom ond the 6as�s
� -- � �� UTILI7Y CO.NOTIFIED � for tho alfeged nxempfion. Any vlolallon of Socuon
��- • � - FINAL ' P c� . 7031.5 6y any appllcant for a parmft sub�ech tho applP
Gnfer oa l+on( . �on}}a a dvll pcnalfy ol not mory}han flve fiundred
� ' � � NOTES ' � � dollars(S500J.: .
� ❑I,as owner of the properry will do ihe work,and
� - � the atructure is no�Intendnd or offered for sale.
� - � (Sec.704�,Bwlness andProfess7onaCode: Tfie Controc-
-- - " - � �-- for's Lfcense Law does not apply to an owner ol properfy
_ who bullds or improvos Ihereon, and who does such
� ' work Btmself provlded}hal such fmprovemenh are no�
__. . . . „ - Infendodorollcredforsafe.lf,howwer,fhebutldingor
� ' � fmprovemenf Is sold wlfhin one yoar oi completion,fhe
�,-�/ ��y y j! ' � ownerv6ulfder wfll have tho burden of prov7ng fhat he did
� � � � ,nof 6ulld or Improvc for the p�rpose af sole.J
'� , , ,
� ' � �I am exompt under Sec. � ,
� B 6 P.C.for this reason
� - . . . .. ' � � Date
, Owner
, .,,� . . . . . . _ . .__ , , . . . .
��•, _
— 't'.5 — , . . � . . . , . i