HomeMy WebLinkAbout1047A WORKERS'COMPENSATIONDECLARATION 70A663 ,o,a� APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affirm that I have a certificate of consent to self CE-BOaG
insure,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY �^��
or a cerfifiad copy thereof(Sec.3800,Lab.C.) . (.il/
P❑ol Ity No. Company FOR AP%ICANT TO FlLL IN !OB �O�q J � _
Certified copy is hereby f��nished. New Residential 81dgs.8 Pools EACH NO. FEE A�DRE55 .c (
� Cer�ified copy Is filed with the county building inspeo 1 8 2-Family,$q.FL � s — E LOCALITY � �„N(J'/'""
tion depariment Mul�i•family Sq.Ft. — NEAREST
Resideniipl Swimming Pools OWNER OR
Da�e Appliconi FIRMNAME OCCe S
CERTIFICATE OF EXEMPTION FROM WORKERS' Out�ets:Rec�ht�Sw.� ` �oDRe55 � C�
COM7ENSATION INSURANCE First 20 J f��
' (Tbi�sactlon na�d nat b�complotad ff fhs work fnvolved by 7otal No. Addifional ��TY Lt/�-L. /If T Tel.No. 2
tho pormiT ic for ona hundrsd dollars(5100)or I�tc.)
PLAN CHECK
I cerlify ihat in the performonce of�he work for whith this APPLICANT
permit is issued,I shall not employ any person in any manner
so as Yo become suhject-ro�he Workers�Compensation Lows. LI9hling fixtures First 20 ADDRE55
Toral No. Additional CITY . Tel.No.
Do7e Applicant � � Fixed Appliances Not Over 7 HP � PERMIT C )
NOTICE TO AP�LICANT: If, after making ihie Certificpte of APPIICANT (� JQCQS �l
Enemption, you should bemme svbject fo fhe Workers' Ronge_Heater_D.W.— .
Compensation provisions of the Labor Code,you must forih- - Oven _Dryer _W.M._ ADDRE55
with comply with such pravisions or �his permit ShoU be Top _.FAU —W.H._ ----"'--'"
deemed revoked. � Hood _Fan _O�her_ CITY Tel.No.
IICENSED CONTRACTORS DECLARATION . LICENSE OR
I here6y affirm ihat I am licensed under provisions of Chapler 9 Disp. _.Room�Air Cond. ..— REG.NUMBER dass.
(commencing wi�h Sadion 7000)of Division 3 of the Business po�,�,er Appamtos 8 Large Applipnces DISTRICT NO. PROCE 5 y
and Professions Code,and my license is in full force ond effect. � � 4
� Size&Type HP,KW,KVA,or KVAR� �
License Number Lic.Class Up to 1 Incl. FINAL V
DATE �
� Over 1 to 10 Incl. VALIDATION Q
Contra[for Date� Over 10 to W Incl. � �
❑ FINAL
I om exempt under Sec. Over SO l0 100 Inc. BY W
�
B.BP.C.for this reason Over 100 �
. Services,Swbd.,MCC 8 Panelboards , N �' � � y'y��� ?
QOfe' 0•200 Amp.Undar 600 V ��"' � yyy,���yyy �
Signoture 207-IOtlO Amp.Under 600 V �'� ��'��`r �� - �
❑ Over 1000 Amp.or Over 400 V .
Exemption for Reg.Moint Elect. ,t
SINGIE FAMIIY Temp.Power Pole&Apportenances ���� � `f ��� �r � � �'j�-�
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I herebyoffirm fhot I om exempt from�he Conirocfor's License Addilional Sign Branch Circuits ` `' �' � � `��r'~
law for the following reason (Section 7031.5, Business and
Professions Code): � i,:��i.�;—�'`�L!
� I,as owner of�he ro er � Misc.Conduits 8 Conducrors
p p ty,will do�he work and ihe �
siructure is nat in�ended or offered for sale (Section Other(Sea Complete Fee Schedule)_ ►
7044,Business ond Professions Code). , -
CONSTRUCTION LENDWG AGENCY . �
I hereby affirm thallhere is a constrotlion lending agency for
the performance of ihe work for which this permir is issued PERMIT FEE (Sub-Tatal) �
(Sec.3097,Civ.C.). � �� '
� PIAN CHECKING FEE �� � �
Lender's Name � � /
PERMIT ISSUING FEE
Lender's Address �� �
I<ertify thot I hove read ihis appliwtion and state that ihe T�TAL FEE
a6ove informa�ion is mrrect.1 agree to comply with all Couny .
ordinances and State laws regulating Elecirical wiring,and �_ .
hereby authorize representatives of ihis County to enter upon � -
ihe bove-mentioned operty for nspecrion purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
��� �ti 3^�-�y
Signoture o�ermittee Date .
. f _ __ _
� , � � ���� " �i.�+ �e+�d'�►..�..s.,.s. �...-�e
,� F , i �.�ia-.�. �ba�. t,r .�r_ ,. . ....
��� ��� "�rs ��s T� 'N y,-w
�C�" �,� } 7 � • r �1 Mrs� s � - .
- � OWN@R-BUILDER DECLARATION
� , APPROVALS DATE SIGN.T RE � � �
- TeMP.POVJ€R POLE � I hereby affirm Ihot I om ezempl trom Ihe Contracior's
Licenso Lcw for the following reason (Setflon 7031.5,
UNDERSLAB WORK � � 9uslness and Pra(sssions Code):Any Nty cr munfy which
� reqvires a psrmlt to cons}rucT,af�er,Improve,demollsh,
• ROUGH CONDUIT
� or rapalr any slrue}ura, prior to I}s lssuance, also re-
� WIRiNG � . , qulr�f1w applicant for wch permlt fo ftle a slgned sfate-
� . F��� , msnt/hot h�Is IFeens�i pursuemt to the proWs7ons o/tho
Contractor's Ucense Law(CFapter 9(commencing wlth
� POWER AUTHORIZED � �- Sxtion 7000)of Dlvlsion 3 of fhe�Business and Profos-
slons Cods}or thof fie!s exempt therelrom and fhe basis
. - UTILITYCO.NOTIFIE� for tha afloged ssempttort. Any violaHon of SecNon
FINAL c7 7031.5 by any appltcaM for a permi�sub�ecis fhe appli-
�ntar on .#ront , cont fo a ctWl penaJ�y of nof more than live hundred
� NOTES , dolfrsrs(5500).:
. � . ❑I,as awnsr of the proparry will do the work,and
� ihe sfructure is not intended or offered for sale.
� (5�.7041,Bmsin�ss and Professions Codc: 76e ConTrac-
tor's Llronse Law does nof app/y to on owner ol property
who buffds or 7mproves fhereon, and who does such
� work himse7f prov(dad that suth fmprovamenfs are not
� inlend�d or of{dred for sale.If,however,fbe building or
- improvemenf 7s sold wlfh�n one year of complafion,the
� own�r•buildar will 6eve the burden olproving that he d!d
� not bulld or(mprove for f6e porpose of sals.)
I am exempt under Sec. ,
� B&P.C.for}his reason
i`
! Date
Owner