HomeMy WebLinkAbout1280A WORKERS'COMPENSATIONDECLARA710N 76A663 10/81 APPLICATION �FOR ELECTRICAL PERMIT �7'
I hereby affirm Ihat I have a certificate of consent to self �E-� . �
i�su�e,o�a ce�rfica�e ofi Wo�kers Compensation�nsuronce, COUNTY Of LOS ANGEIES BUI4DING AND SAFETY
or a certifi copy thereof�Sec 3800,Lab C.�}1
P❑olicy N6%!�✓�Compony ��y��� FOR APPLICANT TQ FltL IN 10B (� /��.,p
Certified copy is here6y furnished. New Residential Bldgs.8 P EACH NO. FEE ADDRE55 J h1�.C...�
I'Q� 1�2-Fdmil � � = E LOCALITY �^ �
Cer�ified copy is filed with the counfy building inspec- y,Sq.Ft. � � �
�'�-� dep iment. Multi-fomily Sq.Ft. NEAReST •-���..,;,,�,,.,..«....,.�....+"'
�� Residential Swimming Pools CROSS 57.
Date�Appl icant OWNER OR
fIRM NAME
� CERTIFICATE OF EXEMPTION FROM WORKERS' OuNets:Rec_Lighl_Sw._ '�'�A�� 3a
� COMPENSATION INSURANCE ADDRE55
Thi���ction need not ba com IWed�f the work Involvod b first 2p
( P y Total No. CITY Tel.No.
tFa permif is for one h�ndred dollors(SI00)or less.) Additional
I certif that in fhe erformance of the work for whith ihis PLANCHFCK
Y P APPLICANT
permit is issued,I shall noi employ any person in any manner �
so as�o become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRE55
/`�� Toto)No. Additional CITY . Tal.No.
L Applicont Fixed Applionces Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, ofter making this Certificote ot APPtICANT �
Exemprion, you should become sobject �o the Workers' Range�Hea�er_�.W.�
Compensation provisions of 1he lobor Code,you must forth- Oven _Dryer _W.M.� � ADDRESS �
wifh comply with such provisions or ihis permit sholl be Top _FAU __W.H.._—
deemed revoked. Hood _Fpn _Olher_ CITY �� Tel.No. �
LICENSED CONTRACTORS DECLARATION pCENSE OR ry
� I hera6y affirm rha7 I am licensed under provisions of Chap7ar 9 Disp. _Room Air Cond. � REG.NUMBER 6 C�OS$�
(mmmencin9 with Seaion 7p00)of Division 3 of the Business DISTRICT NO.: � PROCESSED BY �'
and Professions Code, nd my�icense is in full force ond effect. Power qpparptus 8 large Appliances � q o
Size 8 Type HP,KW,KVA,or KVAR- �r U
License Number�Lic.Class� Up io 1 Ind. � FINAL L�
�+"]� r�� Over 1 to 10 Incl. DATE �], g/�"(i yq��pAT10N �
Contractor' i Da�e (y
❑ —��— Over 10 to 50 IncL FINAI 1�,�.��/y��'� tal
I om exempt onder Sec. Over 50 fo 100 Inc. BY .2f���" / p:
Over 100 �� � N
B.BP.C.for this reason z
Dote: Services,Swbd.,MCC&Ponelboards , .
0-200 Amp.Under 600 V
Signature 201-100Q Amp.Under 6p0 V
�7 Over 1000 Amp,or Over 600 V
I f Exempfion for Reg.Moint.Elecf.
�'^
� SINGLE FAMILY iemp.Power Pole 8 Appurrenances -
HOME OWNER-BUIlOER OECLARATION Sign with One Branch CircuH `� G�'�}a
I heieby aFfirm that I am exempt 4rom the Controttor's License Additionol Sign 8ronch Circuits � ^
law for 1he following reason(Section 7031.5, Business ond {j',c.n • o o�
Professions Code): �
❑ I,as owner of ihe property,w�ll do the work ond the Misa Conduits$Conductors � `'"6�,Q 6
structure is not intended or offered for sole (Section Othe�(See Comple�e Fee Schedule)_ ► s . e:b Y�J��
7044,Business and Professions Code).
CONSTRUCTION LENOING AGENCY O E�v"S CJ
I hereby affirm thot there is o construction lending agency for ��
�he performonce of the work for which this permit is issued PERMIT FEE (Sub-Totol)
(Sec 3097,Civ.C.).
� PLAN CHECKING FEE �
Lender's Name /Q �
GERMIT ISSUING FEE
Lender's Address �
I certify that I have read this applimtion ond state Iho�Ihe 70TAL FEE
above informatian is carrect.I ogree to comply with all Counfy
ordinonces and State lows regulafing Electrical wiring,ond
hereby autharize represenfatives of this County 10 entar upon
�he above-mentioned properry for inspectwn rpos s. SEE REVERSE POR EXPLANATORY LANGUAGE
��-e7 7�I�' � 1'�_
Signoture cf Permittee Date
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� � .� .tIP�RGJA:S P�TE �'� . .� � _. . .. '. �OL'�tN"cR-BUILDER bECL4RATION �
n
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� T£fi�P,P VC�PO�' � � • . h. n6y Qi�'��m tkai a exem t f ori<he Co r cc rr's
. ,. .� .-- --.- — �-----.°----+—-...—. . �.. ',. . . -ce�s.:: Ccw f'r �he foliuw ng r �un (Serrinn 7t331.S.
�- - �� ��.ifql;@kk,;el3�C�} � � Buf.essa �Profnsslorts'"nde)�Anyct7yorcountywhlch
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. . gQ��.�.����. - - i . . � , t'sqg'res cpw.an31 tc c»nsfrutt,clie.,imgrova,Xa�r+olish,
- -- � � � cr repe�°r�ar�y�rructure, pNnr ro its 1:suance, biso�n-
p�
� - ��- 4NIP.IhG� � I�i���,��� ,ry�7 qurasthsap�I7ear,ticrsuthpermit�oftieaslgnzdstate-
` � ���'�!� mer�thct be is Itcensed pursuanf to tbe provislano of Ihe
�. � -�- PiXTb�€5 '. � � Ca7tr4cfars Lfc�nsg Lcw(Chcpfer 4{cammenc+ng with
. ._.._ ..�— ._.y.^7—..._----
Sectipn 730� of DrNs'on 3 af tha Business and Profes-
. . ' ..�r'O�'ER AU FiC}ffi �"i!- � � �I� . .. ).
sions Ca�) r fhct bp�s exemplTherelrom ond±ne basis
. . �JT1'� �Ff Ci7 NC?lF�.:p .y �� 'pm . fdr !Ye adi.. ��! e impiian_ Any vrolatran of Sertion.
��¢�--' c- . .. . 7f/31.5 6y rs�y appHcont far a pem:ii suh�ects ihP appl�-
FINA! �rj�.w�� ,�y,��i� YT� cael fu c c�n!FenolFy of not moro ihan fiva hur-{•�d
� NUTES � � _� � dct}ors iSSOtl1.: . � .
. � � �1,a�ovrr.er o#1ha proporty wi II do the wor4;ond
- - �� __.�_,__ �,., .�._�. the stru�h:rra is not intcnded or oft`e�sd for sple. �
. . , . . - � (Sec.�'144,8usir>ass and Prolessloas Codc�: ihe Controc-
_ ._ � ��� _�y_ for"s L(c*�nst+Lciu doss nof appfy fo an ewner of property
. � � . , u+?sc Ev:Jds or'Improvss iherean, ond wha doas such
� _�__.� _,� .. - '. ,____. ._____ .. _ werk h:n�se?f p;bvfdRd ihat surh�improvements are not
. . . . . . �. � � � � . intended or offerod for stzie.11,howeveq fha�6uildin�or
� , �, , ,__ , �_ _______�__� tmpro��nm�r.t rs xcJd wltfiin arte year ct comple+ion.}hc
. . . ew�sr•t�vilde•'wili havea iho�urd^n qx praving fhof he drd
. . _. _____.,,._—._�__.._...._..______. _ � r.a'r&�t6td er improve for�n�s�nurpesa ct safe.)
.. _a. ._._... � .__�...._...__�___.e.._._ _...._,_..�„�,._,_. .__._ i afn B.:E�mp1 under Ser. �' __.,
� .� .--� —�._.,...._.._______��. _—_______�.�..__m_____ ..�— r�8 P.C.fo-this resason_.._� ��
..._.__� __.—�_....___...._.....__ _e_._--- �..�- ---_�.____
._.._ . . . � -Cate..._.�...------------.._._.._.._._._
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Owner �___....._T- —