HomeMy WebLinkAbout1347A _�-�- �� �'+�+� _ .+� - .
NSATIONDECLARATIOtJ - 76A883 ,o�e, qppLICATION FOR ELECTRICAL PERMIT ��
I I hereby af/irm that I have a Certificate Of Consent to Self insUre, CE-806G
w a certificate ot Workers Gompensation�nsurence,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.G.) .
aCy No. Company FOR APPLICANT TO FIIL IN JOB ����� � �� ,
Certified co is hereb tumished. EACH NO. FEE ADDRES$ ii,� (. ¢',
PY V New Residential Bk1gs.S Pools
� Gertiiied copy is (iled with the county builtling inspection �8 2'Family,Sq.Ft. $ — $ LOCALITY t�����,� ��
department. Multi-family Sq.Pt. — NEARES7 p
Oafe Applicant Residential Sw'imming Pools pWNEft O- � ^��� r`� J
' FIRM NAME (J �', J Iz�1,.�f.d.,��
CERTIFICATE OF EXEMPTION FROM WORKERS' toul� " /1 b S�
Outlets:Rec_Light_Sw.—
COMPENSATION iNSURANCE � . AODRESS �7-L-v. `� ..Y�
(Tbls sectlon neetl not be completed if tha work imolved by the First 20 �
permit is for one hundred tloHare�$100)or less.) Tocal No. Adtlitional CfTY p� . �� ��� Tel.No.�'Y°� 2
I certify that in the perfo�mance of the work for which this permif PLnN CHECK
is issued,I shall not employ any person in any manner So as to APP��CANT
become subject to the W kers'Compensation ws. Lighting Fixtures First 20 ADpRESS
t �� Additional
�-��� � ^ Total No.
� Date Applicant �' � CITY . Tel.No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP pEqMii (� �
Exemption,you shoultl become subject to the Workers'Compensation
R2f1gE_Hed�E1_ D.W. APPLICANT J "G L^�'(�� ��L����
provisions of the La6or Cotle,you must torthwith comply with such Oven_Dryer_ W.M.! ADDRESS�(({ rr-�y.,,�l �w,.
provisions or this permi}shall be deemed revoked. Tap _pAU ` W.H._
UCENSED GONTRACTORS DECLARA710N Hood— Fan _ Other� CITY �,�i��.` Tel.No.���(,� 3
I hereby affirm that I am licensetl under provisions o�Chapter 9 p�sp. —Room Air Cond. � ucENse oft � Ci�s /
(commencing with Section 7000}o(Divisioo 3 of the Business and - REG.NUM6EF �. ��/�
Professions Code,and my liCenSe is in fUll forCe entl effeCt �ISTqICT NO. PROCESSED BY
Power Apparatus&Large Appliances � yh
L+' � /,� , � Size 8 Type HP,KW,KVA,or KVAR �
�icense Number / Lic.Class �'�
! Up to 1 Jncl. FINAL
,f,. Over 1 to t0lncl. �ATE 2 y VALIDATION a
Contractor � -�"✓`� u-�ate �� Over 10[0 501nc1. - �
� FINAL
I am exempt untler Sec. Over 50 to 100 Inc. gy W
6.&P.C.for this reason Over 100 C.
N
Services,Swbd..MCC&Panel6oards ) � � R
� Date: 0-200 Amp.Under 600 V / ��
Signature . 201-1000 Amp.Under 600 V
❑ Over 1D00 Amp.or Over 600 V
Exemption tor Reg.MainL Elect.
SINGLE FAMiIY Temp.Powar Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �
I hereby af(irm that 1 am exempt trom the Conhactor's License Law
for the following reason ISection 7031.5,8usiness and Rrofessions Additional Sign Branch Circuits
Cotle): ;'� '�1! l F�,
❑ I,as owner ot the y, Misa Conduits 8 Conductors • . o
propert will do the work and the structure� pther(See Com I �a 6(
is not intended or offered for saie(Section 7044,Business pete Fee Schedule)_ - �
� and Professions Code�. � .. ���K(�
CONSTRUGTIDN LENDING AGENCY m E �C J,�.:�-�`
I hereby affirm fhat there is a construc[ion lentling agericy for[he
performance oi the work for which this permit is issued(Sec.3097, pEfiMIT FEE (Sud-Total) �4�,C'�-i�i
Cia CJ. � � � �
PLAN CHECKING FEE
Lender's Name �
PERMI7 ISSUING FEE
Lender's Address ��.
I certify that I have read this application and state that the above TOTAL FEE
info�mation is correct.I agree to compiy with all County ordinances
antl State laws regulating Elec[rical wiring,and hereby eUtFtofize
representa[ives oF this County to enter upon}he a6ove-mentioned � � �
� pro��r'�yspection �rpo9es, n._�`��
(� (7 / •�� � SEE REYERSE FaR EXPLANATORY IANGUAGE
�,x L
Signa[ure of Permit[ee �ate �
_ _
_ _ e � _ _ _�
j) ��iiA34 �T7��3 �� 1�1� '." . ., _ .
� --_ --f� i:.�Mr�o; z �++rr�s � ,
- . . , � APPROb'ALS DP.TE � lPdSPcGIOA�S . .- 01NNER-BUILQER OECiA1Rl4A�fi '
SiGNaTUr�E
� TEArP.pOtVER POLE � I hereby affrm that I am exempt from tha Confracrors Lcense
� Law tor the fo!lovnn9 reason(Secffon 7031.5, Quaness errtl
� - UNDERSI.AB WORK � ��rv - Proiessiarrs Code�:Any city or county wh�ch requNes a p�mit
RQUGN CONbUIT - , fo corrswct,afier,improvca,d^mo7is��,m'ry�ai�arry structme,�-�or
.-- __ . - , _„_ __ to its lssuartco,also requires the aoplkant tor such permit to tile
WIRiP3G �� � a srgr.etl sYate�7unt[hat he is liconsad pvrsuarrt to tFe proms�ons
ot the Corr6acta's License Law fChaph�r 9(cammc�rcir+p wi!h
-;E� � � . � fIXTUSFS , : . Secfion 7060)of Divismn 3 ot the Eusiness and Pr•3fassiais
� POWER F�"TWOr�iZE4 � � Code) or iha[he Ps exen�p?therelran a7cf the basr's lor the
. _ . af/ogetl assmptron. Am�vralation of Sectia-i 7(J37.5 dy arvy
UTIiJTY GO.NaTlFIED
� app��can[fa a pe�miY subjecls!he applbm(fo a cir.l penaity
- - � � � ��- FlNAL� ��� L�i'itC?Y Ot2 FY0J2l , of nof more!han Nve hundred tlollars($500):
. N�Tk� � � _. � ' ❑1,ae_,ov{n2r oi the propnrtl vik;6o the wcrk,and the
� s3ruotura is noi 1ntended ar ofEered for salc.
-� - � , � (Sec.70A4,Busirreus ar�d Pro7essions Codo: Ti�e Contrec(or's
� Ltcence Law tices nat apR(y to a�osrie✓of prqRAriy who twrtds
� � � - � � � � o�improves thereon,and who dces such wa�k himsetl pra�ided
� . thaP such lrr�prw�ements bie not.int�ntled ar offere.!fw safe.tf,
� � � � ., hrnvcver,�he buL�ding or rmprovement is softl wifhin ono year o7
�canptctron,the owner-buildcr wiA have the bwden of proving that
. � � � � he did rrot buitd a unprove lw th2 p:r�wse ot sal�.) �
, 7
�- � � � " � �� � 1 am ex�rnpt�nder Sec. - � .
� B&P.C.for this reason
Date
qwner