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Home My WebLink About1281A WORKERS'COMPENSATION DECLARATION 76A663 10/el APPLICATICIN �FOR ELECTRICAL PERMIT {� I hereby affirm that I hove a certificate of consent to self CFBO6G i�s��e,o�o certificote of Workers'Compensation Insu�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY j, or o`e��c�of(Sec.3800,Labw�.)� � /� a� Compony—_ l�V f7 FOR APPLICANT TO FILI IN JOB � Gertified[Opy is hereby furnished. EACH NO. FEE AD�RE55 New Residential Bldgs.8 P��/st� � Certifled wpy is filed with the monry 6uilding inspec- 1 8 2-Family,Sq.Ft.--JC�-F— ; — S LOCALITY a IiQn epa menf. Mul�i-family Sq.Ft, — NEARES7 � �ate �g qPP��a�� , Resideniiol Swimming Poo�s OwNER OR FIRM NAME CERTIFICATE OF EXEMPTION fROM WORKERS' puNe�s:Rec_Light_Sw._ x ��,- COMPENSATIDN INSURANCE FlrS1 p � DDRE55 . (Thls s�ction neod nof b�complNod�F Ih�work{nvolwd by To�ol No. Additional ��TY /�i� Tel.No. � fha pormit is for one hundred dollors(SI00)or lett.) PLAN CHECK I certify ihat in fhe perfarmonce of the work for which ihis APPUCAM permit is issued,I shall not employ any person in ony manner so os fo become subjecl to the Workers'Compensotion Lows. Ligh�ing Fixtu�es First 20 AODRE55 �' � 7oral No. Addirional CITY Tel.No. l ApplimM Fixed Appliances No�Over 1 HP PERMIT � NUfICE TO A7PLICANT: If, after making this Cartificate of APP��p,NT� /� Exempiion, you should 6ecome subjec� to �he Workars' Range_Heater_D.W._ - � � � '� Compensotion provisions of the Labar Code,you musl forlh- Oven _Dryer _W.M._ ADORE55 �� /� / wilh comply wifh such provisions or this�permit shall be Top _FAU —W.H.— deemed revoked. Hood _Fan ,_Other_ CIN �� Tel.N . LICENSED CONTRACTORS DECLARATION LiCENSE OR Disp. _Room Air Cond. g� Class�l �hereby offirm that I om licensed under provisions of Chapter 9 — REG.NUMBER } (commencing with Secfion 7000)of Division 3 of the Business paH,er Apparolus 8 Lorge Applionces DISTRICT NO. PROCESSED 8Y a' and Professions Code,and my license is in full force and effecl. � � Size&Type HP,KW,KVA,or KVAR- ticense Number � Lic.Class� Up to 1 Incl. FINAL iY Comrocior C�G�-��Date �/� Over 1 to l0 1ncl. �A� ��/q/�.� VqLIDATION o ❑ Over 10 to 50 Incl. FINAL �,�y I om exempt�nder Sec. Over 50�a 100 Irx. gy �� N� B.BP.C.for this reason Ovar 100 � Dare: Services,Swbd.,MCC&Panelboards � � 0-200 Amp.Under 600 V � Signatore 201-1000 Amp.Undar 600 V . � Over 1000 Amp.or O�ar GW V ❑ Exemption for Reg.Main�.Elect. T SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECIARATION Sign wi�h One Bronch Circuit I hereby affirm thot I am ezempt from the Controctor's License qdditiono)Sign Bmnch Cirtui�s � low for�he following reason �Section 7031.5, Business and r` � Z H,� A � Professions Code): ❑ I,as owner of the property,will do Ihe work ond fhe Misc CondaNs 8 Condudors �,r� � � �2 structure is nol intended or offered for sale (Sedion Other(See Complele fee$thedule)_ 7044,Business and Vrofessions Code). � � •z 6 3,Q(>. CONSTRUCTION LENDING AGENCY �� "�`i'6 J,O E)c2i I hereby affirm that there is o conslruction lending agency for ihe performance of the work for which�his permit is issued pERMIT FEE (Su6-To�al) Q�,2 5—�,(� (Sec.3097,Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE �Q Lender i Address 1 certify ihat 1 hove read ihis opplim�ion and stote that the TOTAL FEE � above informotion is correct.I agree to comply with oll CouMy � ordinances and State lows regulaling Eletlri<ol wiring, ond here6y au�horize representatives of this CouMy to enter opon . �he e-mentioned property for inspection p p— yr os . SEE REVERSE FOR EXPIANATORY LANGUAGE c�`?l'"l�' e�//�'" Signoture of Perminee Date ;� y�5� '`� ' A �' . i �L i ' I�fT� TJI�� ,�, . .� . � - ... . . i . ,�1F�k!UYtal,�_ DATE �'��'�'7 . . � .�,�.''h'N'cR-6UEL6ER DECY..ARRiICN . �� . . - ..�______._�.._ SiCN'�.CR�f1F - , . . _„ . �TE:�4P_F'DWE32 F:r!.L. . � � I !�ero�y o'�irm thct(am exemp?from th�Contrac�or"s , ' - . . ' -�------- ..-._-- .... .Liat�nss :.c�w for ihe follawinq r�csun (Secfion 703Cr. . - � UNCERStk= Lt�k_K � � � 8vsfnEs cnd P ofmt3lons Cods}�Any clty or rounhy whfcb � LE0t3G�-f C �D IT :�.i � �� rsqutr�s a psr�ritt tc�rrstruci,alre ,�rn�prov��deumai"rsh, ��..„ i- � . . � or vepct a�ry sfrudore,p^tor ta da fss�anto;clso rw- ��Wlk+^.'G' � - � � ' quL-ss the a�pUccnt for such perml��o file a stgnad stafe� . .-�"--�—'�-�' .-�` . �""� mcri tficd he ts ttcsnssc pvrsuan7 to the provlslonc of fh� F�� Cantractcr s Llcense insv Chn te^4 g , .� � t�_�. � _.._�.I ( R (romrna�c(n wittr . -., � . �POVJER At1THC5�ii'� ' � . -_ II . � Saction 7�`JCd;o!b'rvls;on 3 cf rfi�Business wxd Profes�. --{ siar,s Cod_^)cr tl�c!ho,s exempt ihcreiram and the basis , I iJ71lI7Y CO.Adt"�.TEFIE6 � �V s^`^=� . for tfa c�?ic�s�l eremptian. Flny vlolat7o.� oF Sacfion c7 ` . � � 7d3i.5 6y any c�ptic�ni for a permit subjerts�he appl�- , FlNA: a. ..-..'.f n�¢r nn _.r+�n�s�'` ,_�_ cuni t�a c:vil penoFty o!�ot more thcn five.herra��d � � vO7E5 , d��!(t�rW($S`J4j.: . � - - - . , � � � � ❑�i,cs owncr ot tfio prope.riy wlll do the work,�,�nd � . . . � � � ...,_ .�. ihe sire�cture is nct intendce<i or cffered for scie.� . � - ' _ . � i5ec.it��#4,@ucinstss anL�Pr�fecslans Co<Is: 7n�Cor.irat- - , � �� " ' � Tor's ticanx�Las+✓dae�nnf appt y to a��ovmar o(propa•ty � ' , , who builds or�fmproves ffisrc�.�n, and who does such _____...._.._� ._..._._. � ___.__�_�__-. _. �__,__ __. work 61mse?f�+rovld�:that soch im�srovemsnts are not . . � , � . � . - � � � intendedor offtred for sate.!f,however,ehc�huilding or _ � �� _ __ _ � _ . � Improvwrr,�nt Is sold wi+h7n one year of complefion. thc � . . 'owr�e+r.6utJrser wi?f hevr,fihc bvrden n(prav/ng fhcl Fe did _ � � 'rtct 6+�17d cr imp3�ove for ine purpose.o.'sa7e.) _ - -_._ �_�__ .__�_._ , i am cxer.ict under Sc:._ _, _._....�. .—....-- —___--' � �_ .� �_�..�.____._ . 6&F.C.fcr!his roasoc-- --- . �.— �_ �_: _�_-_�_.�_.�___._..___.:. ._ . . _ _ . . � . -. . DOie__...�...,.._________._.-'.._._.- ______� ��.__ �__..�_..._._._..-_.__� ._ . � O,.�ner�._..�.____--- ----_.----- - - .__—_______.� _ _____�_ ..� _..._.______... . . .. . , . 1 .