HomeMy WebLinkAbout1283A 1284A WORKERS'COMPENSATION pECLARATION ���3 ��,8, qPPLICATION �FOR ELECTRICAL PERMIT - �
I hereby offirm that I have a certificate of consant to self CE-806f,
insure,or o certific 1e of Warkers'Compe�sotio��ns�iance, COUNTY OF LOS ANGElES ' BUILDING AND SAFETY
.�cje�rf,Lfied opy thereof(Sec.3000,Lab.C.)
P❑o�icj�Nos���� Company�N� FOR APPLICANi TO Flll IN DDRESS -i T /"�
Certified copy is hereby furnished. New Residentiol 81dgs.8/P�o ,¢ eaCH NO. FEE
� Certified copy is filed with the covnty building inspeo 1&4-Fomily,Sq.Ft.__�� E — �' OCAIITY G� ..
tion/depry tmenl. -/ Multi-fomily Sq.FI. — NEAREST ..
$/�"/ ��/��'�'�1�... � Residen�ial Swimming Pools OWNER OR
Dote"��Applicanf �.Ei�i� FIRM NAME
CERTIFICATE OF EXEMPTIDN FROM WORKERS' Outlets:Rec_Light^Sw._ ODRESS ��.
COMPENSATION INSURANCE fir5t 20
(Tbis sacfien m�d no4 bo compl�fad if tha work Inrolr�d by Total No. CITY Q(/ Tel.No.
the parmit Is for one hundrad dollorc(5100)or loss.) Additionol N�
I certif ihot in the erfarmance of the work for which this PLAN CHECK
Y P APPLICANT
permit is issued,I sholl noi employ ony person in ony manner
so as to become subjetl to�he Workeis'Compensation laws. li9Ming Fixtures Firs�20 ADDRESS
Addilional
,.^ Total No. CITY Tal.No.
Applicont Fixed Appliances Not Over 1 HP PERMI7 //
NU(ICE TO APPLICANi: If, ofrer making this Certificate of - APPLICANT �i
Exemption, you should become subject to fhe Workers' Ran9e_Heater_D.W._ .
Compensotion provisions of the Labor Code,you mus�forlh- Oven �Dryer —W.M._ ADDRESS _,�� `�
wifh comply wilh such provisions or this�permit shall be Tap _fAU —W.hl.—
deemed revoked. Hood _fan _Other_ CITY v Tel.No. G
LICENSED CONTRACTORS DECLARATION � LICEN OR /
I hereby affirm that I qm licensed under provisions of Chapter 9 Disp. �Room Alr Cond. .— REG.NUMBER 3 �Clos ^�
(commencing wiih Section 7000)of Division 3 of tha Business DISTRICT NO. PROCESSED BV d'
and Rofessions Code,and my license is in full force and effecr. Power Apporatus 8 Large App�iances Q
/�J�p-� �//f Size 8 Type HP,KW,KVA,or KVAR� V
li<ense Number �� Q Lia Class_S.._� Up�0 1 IncL FINAL 1 0.'
CoMmc�o�G`�«�C�/ Date� Over 1 to 10 Ind. DATE /�"/9/'�L VALIDATION O
❑ Over 10 to 50 Intl. FINAL L�t�j
I am exempt under Sec. Ovar 50 to 100 Irtc BY {���..y�� N�
Over I0p J+�'
B.&P.C.for this reason Z
Daie: Services,Swbd.,MCC&Ponetboards ►
0-200 Amp.Under 600 V
Signpture 201-1000 Amp.Under 600 V
� Over 1000 Amp.or�ver 600 V
Ezemption for Reg.Maint.Elect.
� SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign wifh One Branch Circuit
I hereby affirm thot I om exempt from the Contrattor's license Addifional Sign Branch Circuits
Law for the follawing reoson (Section 7031.5, Business and t. .� ,��3 A
Professions Code): - �
. � Misc.Conduits&Condoc�ois
I,os owner of�he property,will do fhe work and the �'• o s • �`�J
struc�ore is not intended or offered for sale(Section Other(See.Comple�e Fee Schedule)_ ►
7044,8usiness and Professions Code). � r ��6 3,0 6
CONSTRUCTION LENDING AGENCY
I hereby atfirm�hat ihere is a construciion lending agency for •' {��"U L�.
the perfarmance of the work for which this permi�is issued PERMIT FEE (SobTotal) ���5—8 6
(Sec 3097,Giv.C�.
PLAN CHECKING FEE
Lender's Nome .
PERMIT ISSUING FEE �O ,�1 ��4�
Lender's Address
I cerrify that I have reod this opplica�ion ond sta�e ihat the TOTAI FEE #�.� e. . .�
obove Informaiion is correct.I ogree to comply wiih all County �.
ordinance:and Sfote lows regoloting ElectriCol wi�ing,pnd (.c�e a Q,Q(�
hereby authorize representarives of�his County ro en�er upon .
e above-mentioned property for inspection urpos s. $EE REVERSE FOR EXPLANATORY LANGUAGE
`� ��' �_� ,� _ �z�-.8�
Signalure of Permittee Date
� ` � • � * ��e ' ' { .� '��� � �C� . ��i ., . �
. . . _'A . . • . W�U . � .
,. . , , • . I l�F!s�VAi.._- .p;aTE „ � ..� . ... . . _. .Ca Y�V+cR-6L'14CER DECIARATION � .-- . .
. � S!C`R7ATURf
. . `� TEM� �O;YdFt�P���.c� �� _ '_ ���� _ . , ( hare6y {fi� ,ihct'ari e�ec+rnpt from the Co tra<fcr's
— Lc>nse la f r the fol'awmg reason (Sccnon 7037.5.
- . -��`�UFdC,E�;IAF Nh�f�:F; '��. ., �� ..� . . . Si�aines5 a d R�ofesswns Cade):Any cFty.or carNy which
� - �POUCiC'7 pJl7 ��� � � Qrruirns-aps.mit�fecanstruct,a�f .nprove,'demalish,
�..�„..�......_ __._.�_....� ��._ c. recrot .ary�sirucTure,prlar fa/is�.isiudnco, ofso�e
, �1"J R?�.G ,V �j ����r '��'-, } . . . . . q�^e,the a�plteant for sucFr�armft to£ile a sl�ned stale-
�'F������� -'� , _ nt f6ct he Fs Ifc�nsed p€�rsucnr te tha provlstort�,of fhe
Co�fractars Llc�^nsc+Lew(Chapte>r 9{romm�nc7ng wiib
� ' � � �� . FO1,`E�FlUiF;3f`iZMD �����-��� � � � S€rcti�n 7i1QQJ o7 77v'rstw 7 of the Susiness dnd Profes-
-�-- sions Code.)cr thof ha Is exempl the�efrom and ihe Sasis
. . tJTi!ITYC'J Nt37(Fic�-__� �� lar YY�e ct(a„-ed eu_emption. Any violatlon o! Secnon
. . . F�?�Ai ._. ._....( {° _`..._.J�r ,z`�._..�_ _..__..__�.__., . . ?73t.5 6y cny a�.pl�cant far o perr,rr subjacis thQ appl+-
.__..�._,__ cont to a t7v!)ptvlcl.+y of rtot more ihan f7ve hun��d
Nn7E5 , do?Icrs($50CJ.: .
' . ' � f�i,¢s uFvner of tho prope��ty will do the work,.,nd
� � � � � . t�o strurti�ra is not intendn�or offe•od far sele.
. � . .. � .. . . (Soc.A'�44,6usirtess anf Prof�ssia.�s Cod�... Tne Confrac-
.v___„--,_,�. _. . T--�,,,,,._ R_ _�_ _„_ �tor i CIc:=nse lau�d�es not ap�ly to an oume�of p;operfy
�� . . .. � � � . . who bi�+Ics w��'tmpraves fhorevn, and who does soth
..�. � ._______��..,_._._._���. _.._.. . v _��._,._._�_ work hlmseif prov�tieu�thnt surR tmprovements ore�of
- ' . � � � , irtinndad cr off�red fir scla.If,hov�eve�,fhe butlding or
� ___w_..� _. _..� �.. ._._._._._ imp;aae�rrenf ls safd w�it�y�n one year ot comple�ion,,the
-awner-kwflde�'v.-iN fiavrr ths turder of prpvtng thet he did
.,� „_ � � .rrcr 6rzltc vr imprare�sr tFra ew�pase-bi sp(e.)
. . . �, � � - _ '.��am zx6it�pr undar Sec,�._--.�._..__._.__�.
__ --r- ---�._.. . ---- - ».,._ .____ . �- 8&P.C.far inis r<:ason-- ------
, .___._r. -------'_ --� _-���__�_ �_....._,_.� �at�� ..--- .�,..._._.�. _
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