HomeMy WebLinkAbout1282A � - -,s• � .
WORKERS'COMPENSATION DECLARATION 7GA663 ID/81 APPUCATION �FOR ELECTRICAL PERMIT �
I hereby affirm that I have a certifimle of consent to self CE-&76G
i�su�e,o�a ce�rificare oF warke�s'compe�saron�nsu�a�ce, COUNTY OF LpS ANGELES BUILDING AND SAFETY
or a certifi copy thereof Sec 3800,Lab.�C.)/
PoliCy N���Qbmpany N`��� FOR A►PLIGANi TO FILL IN A DRE55 � I S 4
� Certified copy is hereby furnished. New Residentiol Bldgs.8 s EAGH NO. FEE
� Certified mpy is filed with ihe munty building inspec- 1 8 2-Family,Sq.ft.��T S ` s LOCALITY d' ��
�'�� t' n ep rfinent. ♦�,f� �,,�/y Multi-fomily$q.FI. NEAREST
���� //,m U� A���U Residenriol 5wimming Pools CROSS ST.
Date Appli<ant OWNEROR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_light_,_Sw.__ '�"'41L
COMPENSATION INSURANCE AD�Re55 i ,
Th(s section need not 6a com lated ff}he work involvad b First 20
� P Y Tota1 No. Additional CITY (,� Tel.No. �
fbe permA ia for one hundrad dollars({700)or leas.)
I cerlif fhar in the erformance of the work for which this P�AN CHECK
Y P APPLICANT
permit is issoed,I shall not employ any person in any manner .
so os to become subject fo the Workers'Compensation Laws. Lighting Fixrvres Firsi Yfl ADDRESS
,A`^ Total No. Additional
CITY Tel.No.
[ Applican/ Fized Appliances Not Over 1 HP PERMiT^
NulICE TO APPUCANT: If, afrer making this Cenifica�e of AVPLICANT � ��
Exemption, you should become subject to the Workers' Range_Heater_D.W.�
Compensation provisions of fhe Labor Code,you musr forth- Oven _Dryer _W.M,� ADDRE55 � /
wi�h mmply with wch provisions or this�permii shall be Top _FA� _W.H._
deemed revoked. CITY (� Tel.IVo. �
IICENSED CONTRAGTORS DECIARATION Hood _Fan _Other^
UCENSE R
I.hereby affirm fhot I om licensed under provisions of Chapfe�9 �isp. _Room Air Cond. — REG.NUMBER � � ��OuC��
(commencing with$ection 7000J of Division 3 af the Business pawer Apparatus&Lorge Appliancas DISTRICT NO. PROCESSED BV A�.'
and Professions Code,and my license is in full forca and effect. J �
/'+�/�r Size 6 Type HP,KW,KVA,or KVAR� U
License Number_��Lia Class�� Up to 1 IntL FINAL �-'
� �yy, Q/ Over 1 to 10 Incl. DATE /�/c�/�'� � yAUDATION �
Contractor�/����� Date_.(��6SF Over 10 ro 50 inci. fINAL �
❑ I am exempt under Sec Over 50�0 1,00 Inc BY � N
8.8P.C.For this reason Over 100 L+
Date: Services,Swbd.,MCC 8 Panel6oards � �
0-400 Amp.Under 600 V
Signature 201-100q Amp.Undar 600 V
Over 1000 Amp.or Over y00 V
� Exemprion for Reg,Moint.Elect.
' � SINGLE FAMIIV Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER�ECLARATION Sign with One Bronch Circoif :��� '�H.G P�
I hereby offirm fhat I am exempt trom the CoMroUor's Litanse Additlonal Sign Branch Circuils
Law for�he following reason(Section 7031.5, Business and
Professions Code�: 1?a+ • � �`�
❑ I,as owner of the o ert Misc.Conduits 8 Condoctors
pr p y,will do the work and ihe Other See Com lele Fee Schedule � �°�°6 3�0 6
strucWre is not intended ar o4fered for saie ($eUion ( P )—
7044,Business ond Professions Code}. , �, �; "��,O��,
CONSTRUCTION LENDING AGENCY (1 S.2 5"�5 6
I hereby offirm thot there is o tonslruction lending agency for .
the performance of ihe work for which lhis permit is iswed PERMIT FEE (Sub-Total) �
(Sec.3097,Civ.C.).
PIAN CHECKING FEE �
Lender's Name
PERMIT ISSUING FEE �
Lender's Address
I certify ihat I bave read this applicarion and state that the TOTAL FEE
obove informanon is comed.I a9ree to comply wiih all Caunry �
ordinontes and Stale lows regulating Elecirical w ing,and -
hereby authorize representatives of Ihis Counry to emer upon -
ih above-mentioned properry for inspection rp_� SEE REVERSE FOR EXPLANATORY LANGUAGE
E`s'I,67✓ O( �.JCL.C� �/�
SignoNre ef-0ermittee Dote
���i �1 y.• . �1 I � � �-.e • !l�I'� '• . . . �� .
� . � � aa=a�va,�.., oar�. �'� -._ - •�w��eR-auiGdea�.nec!aRnrioN�.
. .. ' . . . .�_»�._ SIG__�__.'A7c1� . . . ..., .
�TEN t�4 E. E'O E � . ( �� . her��vy af#irra lhar I om exempt from 1he C.ontractcr's
---- t' --- � � � � _nsc, ld+x for 1he follov.�"�g r�i�on j5ecfoo 7031:5,
- ' � �U1�._.ERa=%+91��.:�rv I � ' . . d.slness and Professt ns"'ode)�Anycity or co .�ywhich
� �P�UGFi CQt�7U!T `._.���'_._ . ... , r�,lrros a�r�+'mtt tv:honstruct,alter �prev c�gmolish.
' . . _. �..�����i__-___-y��� r'�� cr�-e�„crtr xy strnrture p-ior ta ns Issuance, a(sa rr-
� .. i WIR,NG � � . . qulras tns og,�pltc..nt(ar auch permtt io!�!e c xtgnod state�
. . . FEX�hU�iB�.�._.��W� ... `..Y menf{hpt ht�is licensed pursuanf io bhe provislon^.o!ihe
, � ��.�___�_,m„__:___ti� Con}:grfar's Lfcanse Law(Chapfer 9(comrr,ancFng wlfh
� - � . �FO ER A�TH`3RI EC � � �� � � � � � Sexrtion 7DCu)aI Div�sron 3 ef the 6usincss and Profez�
1J LITY CO h�0"fIFf�D � � � � s'ons Code)r.r!ha}ba is exempt lherefrom cnd the bosirs
. ��rv� t #cr ih,�r att�ga� examption.�Any Woloi,on oi Seciion
Fi�lAt t: � ' 703).5 6y eny cpp7izant tar o permlt subjecfs ihe appU-
. . t_n�er on _�rnn#`� _ . canf to a civit penalfy of not more than f�ve hw�rad
' NOTES ._..__.._..._ �_�.�...._.____._.� _ d�Hor.s{530Qj.: , ,
.. - � . � � � , ,�I,as owner nf tt:e proaerty wili do 1he worA;��nd
� ,,.__„_,_„_. », — - _ tnn strurture is nnt intendvd or offc�Ed for sale. �
- � _ � . . . . (Sot�.F�J-".4,6usinassondPfo'ess?onsCcds: iheContrac��
. ��� � � � . . �for's[fcEnae Lo,v daes noi appty lo an or:nar of properry
� � � ' - �� whc L-oi[ds or�Improv�as therean, ond who does such
-� � �� — _.,::_—__���_._.�. _.._,....,..... __�..�_� _ w�rk h'rmsatf pr�vidnd that sutb fmprovemeMs ore not
. _ � , . �, - - - � � intoadec!or nffared fo.•5ole.tE hawever,the 6uilding or
__._.___ _-- ._�_ . �_.__.______. _.��._. .�_...� � improvement r,,xci<f wi"h!n ene year cf compietPon,ihe
� ownor-bulJde?'wrid hava the b�rcian af pravinq lhcf Fe did
� _ - nc"�h7-1fd ar imgrove for iha pvrpax'of saFc.j ,
� __ i am.ext,;-�npt�a�dsr Sec:�_rv_._._�_ _.
� _ _T__.�--_-----`—'-------...__..-_.___ _._��_. 6@ F.C.for ihis reasnr..:-- ---�..,..,
��__.....�.____._�_ ���..�_.... _._.._ .. -- . � . .Dtrte..�.._.----�._ __.._
---- --."----�---...._._..._.—_....___.._.�_��.......�m____ — . .
- -- Own�r_�..�__..__ . . _
'.�.'1-�� � � , . .,