HomeMy WebLinkAbout1297A WORKERS'COMPENSATION DECLARATION �bA�3 �o�s� APPLICATION �FOR ELECTRICAL PERMIT � �
I hereby affirm thot I hove a ceAificote of consenl to aelf �E-B06G .
+�su�e,o�a cen�fimte of Workers'Compensmion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or[9��'C +ifi�co y thereof(Sec.3800,La�b{.�C.)
PdfTc�1�. ��5�/ Company �/K� FOR APPLKANT TO FILL IN JOB p
� Certified topy is hereby furnished. New Residential 61dgs.8 P EACH NO. FEE AD�RESS � �?
Certified mpy is filed wi�h ihe munry 6uild�ng inspec- �g 2-Family,Sq.Ft.� � — ; �p�+��TY �'��
figp e tment, ,✓J Multi-family Sq.Ft. — NEARE57 .
�! ,/�,/�(�G"s.//(Ili Residenfial5wimmingPools CROSSST.
Date Applimn� � OWNEROR '/��.y,�
FIRM NAME /j W
CERTIFICATE OF EXEMPTION FROM WORKERS' putlets:Rec_Light_Sw._ �MAIL D, �
COMPENSATION INSURANCE aDDRE55
Thls sattion na�d not b�com leted if fho work involwd b Firit 20
� P Y To�al No. Additional QTY n/' Tel.No. �
Iha permit is for one hundred dollars(Si00J or lass.) vL4N CHECK
I certify thoi in ihe performance of�he work for which thls APPLICANT
permif is issued,I shall nof employ any person in any monner
so as to become subjed io the Workers'Compensa�ion Laws. lighting Fixtures First ZO A�DRE55
/^ Total No. Additional
CITY Tel.No.
�' °PP11CO^� Fixed Applionces Not Over 1 HP PERMIT
NU(ICE TO APPLICAN7: If, ofter making this Certifimte of APP���M� � (� — �,
Exemption, you sho�ld become sobject to the Warkers' Ranqe_Heater._D.W.,_ -
Compensation provisions of the Labor Code,yo�m�st forth- Oven _Dryer _W.M.� ADDRES$ � /
ith comply wifh such provisions or Ihis permit shall 6e Top �FAU —W.H.—
deemed revoked. Hood _Fon _Other_ CITY ��f Tel.No. �
LICENSED CONTRACTORS DECLARAiION LICENSE OR p-
I hereby affirm thot I am licensed�nder provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER �6 Class.� }
(commencing with Section 7000�of Division 3 of the Business DISTRICT NO. PROCESSED BY �-'
ond Professions Code,and my license is in full farce and effect. Pa`^�er Apporotus&large Appliances �
�5 Size 8 Type HP.KW,KVA,ar KVAR C b
License Number-1��Lio Class — v Up to 1 Incl. FINAL a
GJ�I,/"�«'{- Date � C� Q`f Over I 1a 101nc1. DATE ��,/c�'/,�. VAUDATION �
Conirac�or Over 1�to 50 Ind. W
❑ FINAL �
I am exempt under Sec. Over 50 to 100 In<. BY
8.8P.C.for this reason Over 100 Z
Date: Services,Swbd.,MCC 8 Panelboards ,
0-200 Amp.Undar 600 V
Signature 201-1000 Amp.Under 600 V
� Over 1000 Amp.or Over 600 V � .
Exemption for Reg.Maint Elecl.
' SINGLE FAMILY Temp.Power Pole&Appurlenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Cirtoit "
I hereby affirm ihat I am exempt from�he Cantroctor's License qdditional$ign Bronch Circuits
Law for the following reasan(SeHian 7031.5, Businass and � .
Professions Code�:
❑ I,as owner of ihe properly,will do Ihe work ond the Misc.Condui�s 8 Conductors :�� c 9.7 A
structure is not infended or offered for sale (Setlion Other(See.Complete Fee Schedule)_ ,
7044,Business and Professions Code). #�`e.n . e •�
CONSTRUGTION LENDING AGENCY I ""f>d s G
I hereby affirm Ihat there is a conslruction lending agency for
ihe performance o4�he work fo�which this permif is issued PERMIT FEE (Sub-Total) ' �, E c.(,,�.,5�•(��
(Sec.3097,Civ.C.).
PLAN CHECKING FEE �;c�•��..8(� �
Lender's Nome �D
PERMIT ISSVING FEE
Lendei s Address
I certify ihat I have read this applicalion and stafe that ihe TOTAL FEE
above informotion is correct.I agree ro tomply with pll Coumy
ordinances and Stote laws regulating Eleciriml wiring,and
here y authorize representatives of Ihis Couny to enter upon
ih o�e-me�tioned properry for inspection porpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
�� � �
�
SignoWre ef Permitlee Date
!YI�l ki-�a � �.. • � . � `�� } !�� il,���.#���1 � . � .
� . . - � ' ,. � '�E,.a
�� Ar"?R;�VWlS �fi75': , . . . . . .Q,�,bi3ER�tUI�DER DECIARATION .�� ,
- Slt"NATi1�E � . ..
� T�AP,PONIkF N�LE ' � � � � i herPby eff��m thp+-�i am exemp•from Ihe Contracfnr's
. . ...�� .� �, r------------- � �--,---' .. � �-'--' '�� . Licrnsr� �aw far tho following rao¢on (S�,cffan 7031,5.
.:
3 1Jh.D�R$,A6 4102f: � ' � . !`vslnes,an�Prcfcss7nns Cudt>) Any ertye nr eounty wMeh
� —�_�,...�--..���.rv'�Frt,��� r viros a .Mmit to,eanstr�rt�,alfer,im rove,demofish.
._ . ,�Uiii CC7FJ�lJiT ; . � . . . I . ..� . . �.. � �� P
� � . -}------ ' ' -' or re(:afr crny siruCfure, prlor ta ih tssuvnce, olso re-
�- � � V4'iRl^='v y i � � t� � �ufrse ths ar,p:l7rcn±for sLch permit ta(i1e a slgned stato-
. ,. . .. ��_.�.:,....__�__:_,...'._' _'. � mc-nt/hat he 7s Itrenser!punumrtf ta tho provisions oi tl�e
� : Cpntrp;.fo.*'s!lten5e taw(Chp�t�r 9(comme.ncing wl�h
.. {---'.. ___�____.___.
� � ' � � -��PGYI'ER AUTFr�R'ZE5 -- -� T^� � Secrtvn 7CL�'3j ef Divrsiar 3 of fhe 8us�ne,s cnc�Protss-
-i-------- -----� sior,a CadeJ or thal h�!s excmpt ibersSrom cnd the basis
U7i!I?Y C��� . 4 . far the: a;iegad exe.�npSion, Any violo3;orr of Seeilon
� � � �� n �'m�p .' 7�73t,5 b an• o (tc�}�'or a ermit sub eefs thes a t
�F�P?Ai `- � -"����� � � Y / R�P� P 1 PP�-
. �`____ C rsfnw crc�3rnrf� .-, � . � con4 to a cDvit pena3fy ol ncl more thon l/vo hur^��nd
NG7E5 . . . . do!Fars{,SSG�:j.: �
� - - . . .� -- ., . ��-.'I,aa awrar of iFa prop�rty wil!do ihe work:��nrl
. � � � � - ______� ______y ±he srrue�wre is nat intended or offered far sale.
. � � . �� �� . ;Ssc.7pdt,3usin<uss and Froft•sxions Code: The Confroc
-�____` --_.._._ .. . � ____,.__...______..�._._.____....�.__._.._..__. _ � lor'S ltesnse lcw dnnz not oppfy tc an ownsr of property
. , . ' whc 6u.ld; or-Improvez therteorr, onu wl�e does wrh
'•� � �� � � �� ,. � wurk hp»rs�lf prav�dewi that such�improvwnenrs are not
_._.____,._ �__ �....._.�._�_— _�_._"_.____.__.�__.
� � � . ' ` - � ' � � - - irsfe�nCad ni atfored i�r sale.(/.howov�r,fhe bvlld�ng ar
___� � ____ �_______ �,,, .,.� �� +mproverr.eni rs zatd wiiAin on+a year of comptetion,ihe
, - , . � � own�r-bu�iderwtl}i��ye fhe bur8en ol pravt»g tRat he d;d
.�. ���.`. _ ______; rvo'bu1t�Qr improve for}h�uwyoFi.sY��cf sale.l
� � -� � - ' `d.am ea4?r`npt undnr S�c., :�..__,___. ,
_._.__ _W..�... _� ..�.� ....�. _.____�.._�_—. . . . _.__. ..8 3°.C,far this;eason_._.--.. � .
__.__..._.___.._.__ ___..__. _.....__�---....--------
—___.�_..__._.__�___. _
.. . . , � � �� � � Dnfe----_---------'—
�.----- - -----�._..._«__�__:---_._�__..._..__-__�___.��_._._.... ._.
� i�wn er._._.,.__.._��_._______—.... ._
_ •'r. , —A. . .