HomeMy WebLinkAbout1698A K 'COMPEN3ATION DfCLARATION �bA� ,o�B, APPUCATION FOR ELECTRICAL PERMIT �
1 here6y offirm that I have a certificate of consent to self CE-606G
ins�re,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGEIES BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,lab.C.)
P❑alicy No. Company FOA APPLICANT TO FILL IN JOB `` p
Certified copy is he�eby f�rnished. New Residentiol Bldgs.8 Pools E�1CH NO. FEE aDDRESS�^/33 3 �I �SjqF�c.
� Certified copy is filed with ihe county building inspec- �&2-Family,Sq.Ft. E = E LOCALITY � �'fLr�j,/v, � L��'
lion de arfinent. Mulli-famil 5 H. NEAREST f
p Y 9' CROSS 5T. �OL S�/��A�d"' �"�N�
Date Applicon� ResideMialSwimming Pools OwNEaOz �j�{� p[J /
[� iMMMVAME /7/7 7F- �///��` UFFd�
CERTIFICATE OP EXEMPTION FROM WORKERS' Outlets:Rec�LigM�Sw.! �`�''0'«
COMPENSATION INSURANCE nDOREss S %Y!''7�-
Thts�eefion nasd not bo com l�fad IF ffw work involvad b � First 20 � �,
� P y Total No. 3 Addilional CITY iel.No.���_�'s�+,�
th�permft is for one hundred dollan(;100)or I�cs.)
I certify that in the performance of the work for which this � APPN AHNETCK
permit is issued,I shali noI employ any per5on In any manner Q
so as to eco subjeU to fhe Workers'Compensation Laws. Lighling Fixlures Firsf 20 � ADDRE$$
7 -�' Total No._1� Additional
Date �g Applica � � �' � CITY Tel.No.
NOTICE T APPUCANT: If, ofter making iFiis Ceni e of Fixed Applionces Not Over 1 HP PERMIT ,p rG �r
Exemption, you should become subiect to ihe orkers' Range_Healer_D,W._ APPLICANi ,/c.. (��"r�/��
Compensotion provisions of the Labor Code,you mus�forth- Oven _Dryer _W.M._ ADDRE55 p �
with comply with such provisions or this permit shall be Top _FAU W.H.—
deemed revoked. � Hood _Fon CITV Tel.No.
LICENSED CONTRACTORS DECLARATION ���her—
Disp. �Room Air Cond. _ ��� LICENSE Ok Class.
I hereby aHirm that I am licensed�nder provisions of Chapter 9 REG.NUM�E��
(commencing with Section 7000)af�ivision 3 of the Business powsr Apparatus 8 lorge Appliances DISTRICT NO. PROCESSED BY �
ond Professions Code,and my license is in full force and effeci. �� d
Size 8 Type HP,KW,KVA,or KVAR� �
License Nomber Lic.Ciass Up�0 1 Incl. FINAL �
V
Over 1 to 10 Incl. DATE �0/1 y j,.�.i yq��DATION �
Contracfor Dale Over 10 to 50 Incl. � F-
❑ FINAL
I am exempt under Sec. Over SO ta 100 Inc. BY � W
B.&P.C.for fhis reoson Over 10p �
� Services,Swbd.,MCC 8 Panelboards � � Z
. ❑ote: D-200 Amp.Under 600 V .
Signature � 201-1000 Amp.Under 600 V
❑ Over 1000 Amp,or Ove�600 V .
Exemption for Reg.Moint.Elect.
SWGLE FAMIIY iemp.Power Pole 8 Appur�enances 1 1 6 9,8 A
HOME OWNER-BUIL�ER DECLARATION Sign with One Bronch Circuit �+��� � � �2
I hereby affirm thof I am exempt from fhe Coniraclor's License Additional Sign Branch Circuits ' �
Law Por the following reason(Sec�ion 7031.5,B�sinsss and ��• .6 3 5 p
Professions Code):
,/� I,as owner of fhe property,will do the work and 1he Misa Canduits 8 Conducfors � • • •(}j,,�,���
strutlure is not intended or offerad for sale (SeUion O�her($ee Complete Fee Schedule)— �
7044,Business ond Professions Code). O Z L S"��J
CONSTRUCiiON LEN�ING AGENCY �
I hereby affirm�hat there is o consnuctian lending agenry for �
the parfarmance of Ihe work for which this permit is issued PERMIT FEE (Sub-To�al) s
(Sec.3097,Civ.C.).
���� PLAN CHECKING FEE . .
Lender's Nome
. PERMIT ISSUING FEE IG "� �
Lender's Address �2
I certify thot I have read�his application and sfate ihat the TOiAL FEE j
above intormation is correa.I agree ro comply w�th all Coonty _
o�dinances and State laws reguloting Eledrical wiring, ond � �
hereby outhorize represenfatives of this County lo enter upan �
the obove-meMioned property Por inspection purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE
�-�'.�r'. ..E Q 7-.�S-�'',S'
Signofure of Permlft� Date .
# � �� � •k "'q'r i.� ��
'�'' �� . a.� . � �
"'�'\ii�y ��A� � ��� �6/�- r�. - '
� � APpROU�tS pqTE OWNER-BUILDER DECLAR,4T1afJ
SIG�PIAT RE
� T6MP.PE7WER POLE � I haroby affirm ihat I am exempt from ihe Confro<br's
- � - License Law fcr the following reoson (Sedion 703L5,
� � UND9ASLAB WORK Bustnass and Professlons Code):Any clty or county whlch
ROUGH CON�kIIT rsqulres a permH to consfruct,aker,�mprove,demollsfi,
. �- - � , � or rupair arty strutture,prio:to its Issuanoe, also re-
, yJip1N6 � \ � qulrn Hro applleant far auch p�rm�t ro ftle a signsd stoto-
. � PIMURES � ment fhat ha ls fieeeasedpunuanf to the provislons af�Be
� Conhaclor's Llcsnsa Low(Chapter 9(commencing wNh
FOWER AUTHORIZfO � � Sedion 7000)o�Dlvislon 3 of ihe Business and Profes-
� s/ons Cods�)or tho/he Is exempl therefram and the basis
UTILITY CO.NOTIFIED for tfie efl�ged exempTlon. Any violatlon of Ssttion
� FlNA! n 7031.5 by any apphcanf for a permit subjeats tha appli-
Gnt¢�oR �nf � cont to a ctvll penalty of no!more fhon ilve�hundred
ME1TE5 dolle�s(5500).: � � �
� ❑i,cs ownar of ihe property will do the work,and
� � ' .ihe shucture Is not intended or offered for sale.
(Ssc.7044,Buatnrsa andProfesslons Code: 7he Contrac-
for's Llcense law daes not apply to an ownor of property -
� who bullds ar fmproves fhereon, ond who does such
work hlmself provldsc'thai such improvemenrs are not
In}endsd or olfered for sale.If,however,}he bulfding or
improvemen�!s sofd wliFin one ysor of complet7on,the
� ox•ner•6ullder will have Thc burden of proving fhat he dld
nof 6uild or improve for ihe purpose af sale.)
I am exempt under Sec. .
B&P.C.for fhis reason
Date
Ownar