HomeMy WebLinkAbout1295A WORKERS'COMPENSATIONDECLARATION 76a663 10/BI APPLICATION fOR ELECTRICAL PERMIT � �
1 hereby affirm that I have a certificate of consent ro self Ce-ea6G
insure,o�a certiFlmte of Workers'Compensafion��su�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a/�r i o y ihereof(Sec.3800,Lab.sCf.�) �
a��� .�Company �!� � FOR APPLICANT TO Flll IN J08 � .� .
Certified copy is hereby fumished. New Residenfiol Bldgs.& EACH NO. F E AODRESS
� Certified copy is filed wi�h�he counly b�ilding inspec- 1&2-Family,Sq.Ft. �'�',�T E — 5 LOCALITY �
��' li par ent �'yj Muhi-family Sq.Ft. — NEAREST
%/ Residentiol Swimming Pools CROSS ST.
Date qpplicont /q��� OWNER OR �
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Oullefs:Rec_Light_Sw._ � MA�� /��
COMPENSATION INSURANCE ADDRE ,.7
(Thfs secfion need nof 6�complNod IF tba work involv�d by Fi�st 20 `�
Tha permil ts for one hundnd dollors(5106)or I�ts.) Total No. Additional CITY Tel.No. �
PIAN CHECK
I certify�hai in the performance of the work for whith Ihis APPUCANT
parmit is issued,I shall nof employ ony person in any monner
so as to 6e�ome subject to ihe Workeri Compensation Laws. Lighting Fixlures First 20 ADDRESS
Additional
F" Totol No. QTY Tel.No.
APP���p�� Fized Appliances Not pver 1 HP
NUTICE TO APPLICANT: If, after making this Certificate of PERM�T �`/ �'
Exemption, you should become subject �o �he Workers' Range_Heater_D.W._ APp�iCp`N7
Compensation provisions of the Labor Code,you must forth- Oven _Dryer —W.M._ ADDRE55 �O�
with comply with such provisions a� ihis permit shall be Top _FAU _W.H:._
deemed revoked. Hood �Fpn _Other_ - CITY - Tel.No
LICENSED CONTRACTORS DECLARATION uCenlSE OR q,� �
Dis _Room Air Cond.
I hereby pffirm fhot I om licensed under provisions of Chopter 9 P' — REG.NUMBER (/(J Closs.
(commencing wi�h Sec7ion 7000)of Division 3 of ihe Business power Apporatus&Large Appliontes PISiRICT NO. 1 PROCESSED BY � �-�
and Professions Code and my license is in full force and effect � Q
r�y f� Size 8 Type HP,KW,KVA,or KVAR �� � U
License Number�lic.Class_�_C_.� �.S
M Up to 1 Incl. fINAL
�-/_ Over I ta t0lncl. DATE �),/g/g(,. O
Controctor���� Date�'S1}L YALIDATION � U
aOver 10 to 50 Incl. FINAL W
I om exempt under Sec. pver 50 to 100 Inc. BY � �
6.8P.C.for this reason Over 100 Z
Services,Sw6d.,MCC 8 Panelboards , .
Date: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 60p V
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.MaiM.Elect.
�' SINGLE FAMILY
Temp.Power Pole 8 Appurlenances
HOME OWNER-BUILDER�ECLARATION Sign with One Bronth Circuit
I hereby affirm that I am exempt fiom ihe Coniracror's license pdditiono�Sign Branch Circuits �
Law for the following repson (Section 7031.5, Business and
Frofessions Code):
❑ I,os owner of ihe property,will do Ihe work ond the Misc.Cond�ih&Conduc�ors f�1_2 4,5 A
shucture is not intended or offered for sale (Section Other�See Complete Fee Schedule)_ ► $=� •T a r 2
7044,Business and Professions CodeJ.
CONSTRUCTION LENDING AGENCY I "' �6�8 b
I hereby affirm 7ho1 fhere is a cons���ction lending agency for
the performance of the work for which fhis permit is issued pERMIT FEE (Sub-Tolal) o '" '"C?u L�%�
(Sec.3097,Civ.C.).
VLAN CHECKING FEE � O�E.����b
Lender's Name
PERMIT ISSUING FEE Q �
Lender's Address
I cen�fy�hat I have read this applica�ion and srote�ho��he TOTAL FEE �
above in4ormation is carrecL I agree to comply with oll County �
ordinances and State lows regulatinq Electriml wiring,pnd
here6y aufhorize representptives of this County to enter upon
i,�he J°ove-mentioned properry fo 'nspection purp es. SEE REVERSE FOR EXPIANATORY LANGUAGE
S-2t�� ��yl�'� 8' 8'
Signature of Permiilee Date � �
�, � . � � . • ,� .� ��_ + i�l C�i!'A.)' •`*�/t
,� .. m
��---7--7�g� ov+,v��-auao�c;oGcrAaaripN :,
. � �. , kFr^.4JAtti DA.TE . i 'Sj�GVATi1`.w� .� �� .... . . . �.
. . • .. � T�h P PO'.i�R P�;.E. � I �_.._. . . � hercahy c�f rr,tho?I a .+ce�rpi fro.,�fh,e Co tractor's
--+--------�---� � . �� .. - � .��cer+sa :aw for 1he folacwing en or 15ec}on 7031.ri.
�� ` � �KSi.4o�"lt72K �. . .. . �" . Fusin�s;an�ProFessfans C'o'e;:Any crtY a ��nry wh-ch -
. . ^�OltGli CO!^d;.'7U!' ____.�._ ---_�.�.�.r_ �� �.� .. re �r^ c',s -,.7�.` .
i � q .F c-tmtt fo cansfruct,ah. i o�o�e,demofish.
or-repmr any sfrueturn, prlor to fs issucrtce, also re-
.�y�,/���rt r� � �—� qufrss fh�r�ppl can!(arsuch Farmlt fo fl!�a s�gned smte-
� � T —"- �"" j msn#Ph.,f he is 1 rense�pursuea£fo thr,p�vtstcns o/tfie �
, r�xr���—.
S► __.�,�_ Contrac3ots Citertae Law(CHaptor 9(can+mencing wlth
r_ �_. __�____
- , . . , ��q;,��,�rJ���Ep�.� �� _� . Sec;ion 7t�bQ;r of Dfvlston 3 af fhe 6usmecs c�nd Profac-
�._ stans C�dm)ar th�t hu 7s exampt ihc•re/rom cnd the bosis
(U7ftItY CO �QT:FPE;� �� {ar thr: wlf�;�s:� axc�rntsfion- Any violatian ol Section
.. .. ..��;���, cry ... . . . � 7D37.5�y a�y appCicant for o permit sub;"ects�fre oppli-
. . . . , �i:fc•s nn. �t�rwnf , . , co�f t�o civfJ�aenaity af not mcre fhan f)vo F,ur3'�d
__.___..__.._.__ _____.�.........d.._��__.._..�_._____�.
NOTES � � do?fars(SSOOJ.:
�� � � . . , � . ,�;i,oa cyuner of ihe properYy�vi41 dv rhe work,nnd
_ _� ' � � _�. .._J._.._� +he s'ruc:ur�is nai ir�tenc3od or olierad for sale.
.' . . f5ec.Td44,�usi.�e�s and F�o!ess�;.ns Cosi�: The Cenfroc-
_W___._, � �� � , _�s tor's ltce�vsc Lcw dc,a.�not a�p/y lo an owrsar ob property
- - _ .' � - � ' . w'r.o buflds ar�lm3rave� th�r�crs, and who daes suth
... . �... ...._�._..�___.�.�_._. wark hirnss�f p;ov�dnd rnar such improv�ments are not
. , � . . , � �� . int¢na'�d ar affered 1or safe.If,�bowever.fhe bullding ar
�,_ �__ _,m � _ imptovem:_��!is sofrA wrthin orte yee�ol romplefion,the
� � � awnenbu€tderwill have the 6urden o{proving thot he did �
. �,�____ _�_____�. . . . nt9 Ev7::'or irnprovc.,€or the"o�rp�as9-of sa(e.)
_�.�..�__.._..__._.�.�__—..... ._._..._..m__�....____m____...--_....._._ ��._�_..: _.._.�..,_.� �� ._..._ , .�am G;xer,-;pt under�5ec..�:�'_._,_._,_,
.—._._ ._.._.._..._.—�---- __,_�__,..�--._-_,_.�---._..____.�......___._... _. _._.. . 6'�:.P.C._far this r�ason,_:.....___._ .—..
.....�_ _. ___._._._.�_._.._.._,_.,.._�__:_.---�_�—_.._.____----'�_.—.� .
. . � . � . .6a?s-._._-...-- —'—
__._. . _ .__._______...._..
._..�..--------._. _._.�._.._.__.
Ovane?r�......__�_��___._ ^
� � . �.f.�' � .
- ._______�_____.._...�.... . .� � . . �