HomeMy WebLinkAbout1378A y► �_r + y*7 • �R._ �' . ![-
WORKERS'COMPENSATIONDECLARATION 16A663 IOi81 APPUCATI4N �FOR ELECTRICAL PERMIT �
I hereby,affirm �hat I have a certificate of consent to self C6ao6G
insu�e,or a ce�rficme of workers'Compensmion�nsurance, COUNTY OF LOS ANGELES BUILDING AND SAfETY
`or a certified copy thereof(Sec 3800,Lab.C.)
a�YNo C2Jt5$957Company IN� FORAPPLI[ANTTpFlIIIN JOB
Certified copy is hereby fumished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
� Certifled copy is filed with�he muMy building inspec- 1 8 2-Family,Sq.Ft. 14l1Q � — E LOCAII
�ion deparlment. Multi-fomily Sq.F. — NEAREST
o� rt u Residential Swimming Pools CRO55 ST. �
DotesL 2��g6 Applicanl T MCCeB L�'.1 eC_triC OWNER OR
F�RM NAME
CERTIFICA7E OF EXEMPTION PROM WORKERS' Outlets:Rec_LigM_Sw._ '�'w��
COMPENSATION IfdSURANCE F,s � ADDRE55
(Thic s�cfion na�d nof b�aomplelad if ebs work involved by Total No. Additional CITY CO i a Tel.No. 6 _
fhe p�rmit b for one bvndred dollors(ti00)or le�s.)
I certify fha�in the performance of the work for which�his pL PNCGnH�K
permit is issued,I ahall not employ ony person in any manner
so as to become subject fo Ihe Workers'Campensation Lows. Li9hting Fixtmes Firs1 20 ADDRES$
Total No. Additional
� Applicant CITY _ _ Tal.No.
h_.�CE TO APPLICANT: If, af�er making �his Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, yov shauld become su6jacl fo the Workers' Range_Heater_D.W._ APPLICAM t�T�� McGee Electric Inc.
Compenw�ion pravisions of ihe Lobar Code,you must forth- Oven _pryer �W.M._ A�DRESS � Q. �px 1111
wilh comply with such provisions or this permit shall be iop _FAU �._W.H:—
deemed revoked. Hood _.Fan _Other_ CITV L. Tel.IVo. �
LICENSED CONiRACTORS DECLARATION UCENSE OR 490D83 Class.C—LO
�hereby affirm Ihaf l am licensed under provisions of Chapter 9 �isp. _Room Air Cond. — REG.NUMBER
(commencing with Section 7000)of Division 3 of the Business DISTRICT NQ � PROCESSED BY G}.,'
and Professions Code,and my license is in full force and effect. Power Apporalus 8 large Appliances � 0�
Size 8 Type HP,KW,KVA,or KYAR I U
License Nomber G90083 Lia Class C�1� FINAL� �
Up to 1 Ind.
Conirocior Electrical Date 8/20/86 Oner 1�o 101nd. DATE �g', yp��pqTlpN �
❑ Over 10 fo 50 Ind. FINAL W�
I am ezempl under Sec. Over 50 to 100 Int. BY N
8.8P.C.for this reoson Over 100 �
��e; Services,Swbd.,MCC 8 Ganelboords ,
0-2W Amp.Under 6D0 V
Signature 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 6D0 V
Exemption for Reg.MaiM.Elect �� ���S A
!`" SINGLE FAMILY
HOME OWNER-BUIIDER DECLARATION Temp.Power Pole&Appur�enonces #i•�e • 0 6'2
I hereby affirm lhot I om exempl from�he Controctor's License ' S�9"w��h One Bronth Cirtuit � s �E���6
Law for the following reoson(Section 7031.5, Business and Addiiional Sign Branch Circuits
Professions CodeJ: , F ,. _
� : �b�.s��
I,os owner of the property,will do the work ond fhe Misc Conduits&Conductars
structure is no�inlended or offered for sale (Section D�her(See Complete Fee Schedule)� � .D`C.G E�-'H G �
7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which�his permit is issued PERMIT FEE (Sub-To7al) S( 36
(Sec.3097,Civ.C.).
PLAN CHECKING PEE �
Lender's Name
PERMI7 ISSUING FEE
Lender's Address
I certify thaf I have reod this opplimfion ond state that Ihe TOTAI FEE
pbove informalion is mrreci.I agree 1a mmply with all County
ordinonces and State laws regulating Eledrical wiring,ond
hereby avthorize represeNatives of ihis Caunty to enter upon
ihe a ve-menYoned property or inspection purposes. SEE.REVERSE POR E7�PLANATORY LANGUA6E
� C R,2o�86
Signature o e�mittee Dafe
' +�Q • . . i � f `� . � `� �a Ir�C1!*11���M`ilk
— � 'OWNER-BUILDER DECLARATION
a.FVPOVAtS_..... _DATE ^SIGNATUkE .- . .
' � � ' -�� - � 1 hnrab affirm that I om exem t from tho Conrractcr'x
- � TrN+P.�R4WFR PCiIE,� Y P
. ' - � lieense taw 4nr rhe folioveing rea.o� {Seetron 7031.5,
-� � �� Ufd�pRS!l16'vVO�K � - Euxi.�ess and Profsss/ons Code):Any cNy or county whlch
� RQ�.>?.{C"SSJD'JIT� �F�� .requtres e perm7f to:construct,al+er,Improve,�.Aemot(sh,
.;.�.�.�...
- ar repdir ony efracture,prlor to Ivs fssvtrrtce;alsa ra-
' NJIPtf',G � � ���7�-g. �:�'��' . qutrea the appllcan!far sush permit to flie a stgned sfale-
Z ; �— � � me�nt thui he�s kcsnsod pursvant fo the provlslons oi fhe
,. 4fIXtJRt3 '� _ �...---
Conf�actor's Ltcense Luw(Chapter 9(commettcing wifh
- - -- � 'PQViCR AU7ksVR},-.tp Se<tinn 700G)of Divlsion 3 of tbe 8wlneas and Pro/es-
; — --- slons Coda}or fhof be ts exempt}hcrefrom end 16e 6asis
'�T�<<�"f-'J�E`+u7�'�-d .for £hu vhngac+ exampftort. Any vlolction o/ Sectbn
FIN�t:,^-,-,�T.---�nf�.r ;�t��;� 7631.5 6y any appltcant/nr a parmft sub��ecis the oppU-
_ can!to o Uvtl pena$y ol nol mara thon flvo hundred
- NOl'E� do!)nrs(SSOC).�
�,.1 . � ❑I,as ownor af th�properry will do ihe work, ..nd
-� - �,_,__ R�_ _ tne strutture is not intendad or offerad for sale. .
� � (Sec.364A,6ustness crvd Profeastans Code: The Conirac-
.. . ... ` . .. . _� � tor's lltense Low�oas not opply�o an awnsr oI properlY
, � , , . who bnflds or�fmprovas therean, and who doss such
_ �� ��- _„_.,__,_, _ __ . - work bims�tf provldnd that such�improvements are nol
' � ' ' In+ended or of9nred for solo.!f,hpwever,the building or ��
___ � _�� _ �improvemant is sald within one year of romp7atian,tba
, o++mer-6uifder wtil hove fhe hurden af provtng tbat he did
„____ _ _ nat.b.ulfd or imprave for�he parpose of�ale.)
_��„_�� I am��xempt undar Sec. � ,
� , .�� , ._... �
�--�— — --- B&F.C.for this ranson
_.�__ —.�.. _._.__. _._... -- "- . - Date .�
. � --"`�----- .—� '^ (Jwner _�_