HomeMy WebLinkAboutNo Permit Number (9) �h'ORKERS'COMPENSATION DECLARATION '6A563 lo/el <A� � S
by affirm that I have a certificate of consent to self =6006G APP1�.fCAT1�ON FO�R ELECTRiCAI P�RM17
�re,or a ce�rifkare of wo�ke�s'Compensauon I�su�a�ce, COUNTY Of LOS ANGE�ES BUILDIN[3 AND SAFETY ���5`� ���
/`or o cer�fif/i�ed�cJop�y,tha�r,eyof�($ec 38D0,Lab. J .
.�� P❑olicY IyM'��nipany� ���f�`�� FOR kPMICANi TO PttL IM JOB / jt� � ��
Certified copy is hereby furnished. 'New Residen�iol @Idgs.8 Pools Ef�H NO, FEE A��RE55 4/
�/' 1 8 2-Famil 5 FI. $ — E LOCALITY m �J�
1LL Certified copy is 4ilad with�he munfy building ins eo Y� 9� _
�t–� tion department. //fj Mulfi-Family Sq.F. NEARESi �r
�j /`. Residentiol Swimming Pools OWNER OR A�� � �
�atea` ���� Applican � �!' " FIRM NAhSE
CERTIFICATE OF EXEMPTION FROM WORKERS' Oullels:Rec_Ligh�_Sw._ �'A��
COMPENSATION INSURANCE ADDRLSS �}
(fhie seclion n��d nof he comphN�d if fF»werk irtvoM�d 6y Fint 20 CITY Tel.Na.�
� Tofal No. Additionol
fl»parmit is for on�hundr�d doller�(fi00)or Itss.) p�AN CHec�
I ceriify thot in the pe�formonce of thr work for wMich this APPLiCANT
permii is issued,I shall not employ any person in ony manne�
so as to becama su6ject to ihe Workars'Cornpe�risation lows. Lighting Flxtures first 20 ADDRESS
Additionai
Total No. C�TV Tal.No.
Dote Applicant Fized Appliances Not Over 1 NP PERMIT
NOTICE TO APPtICRNT: If, after makmg �hls Certificate of APPUCANT f��.
Exemption, you should become subjed to fhe Workers' Range_Heafer—D.W. —
Compensation provisions of�he Labor Code,you musf forth- Oven —Dryer —W.M.— A�DRESS J,'!
with tomply with such provisions or ihis permil shall 6e Top —FAU —W.H.— QTY Tel.Nofi"�S r,
deemed revoked. Hood —Fan _Olher_
LICENSED CONTRACTORS DECLARAT�ON IICENSE OR Closs.
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBfR �T -
(commencing with Section 7000)of Division 3 of ihe Business power ApparaNs 8 Large Applionces DiSTRICT NO. PROCE$ BY }
and Professions Code,and my�icanse is in full force and effeU. �,�� O
� Size&Type HP,KN',KVA,or KVAR � �
License Num6e Lic Clcns�� � Up to 1 Ind. FINAL V
� � Over 1 to 101nd. DATE � �% �C� �iAUDATfQN Q
tu
Comrac� �'�e�� Over 10 to 50 Incl. PINAL ' V
❑ I am exempi under Sec Over 50 to 100 Inc ��BY �����.Y�v✓ pW„
6.8P.C.for this reoson Over 100 �
Da1e: Services,$wbd.,MCC 8 Panelboards ► `
0-200 Amp.Under 600 V
Signoture 201-10IX1 Amp.Under 600 V
❑ Over 1000 Amp.or Over 690 V
Exemption for Reg.Maint Elect. y!
SINGLE FAMILY Temp.Power Pole 8 Appurfenances �� + � ,
HOME OWNER-BUILDER DECLARATION Sign wilh One Bwn�h Circuit
I hereby affirm thot I am exempl from ihe Contractor's License pdditionnl Sign&onch Circuits
Low for Ihe following reason (Section 7031.5, Business and
Professions Code): - -
❑ I,as owner of�he properly, �II do the work ond the M'sc.Cond�its&Conductors
siructure is not intended or offered for sole (Section Other(Se CampleJe Fee Sched�le)_ a O ►
7044,B�siness and Professions Code�. �
CONSTRUCTION LENDING AGENCV £.� 3 9 3 A
I hereby affirm fhot Ihere is o consfrudion lending agency for -
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) h• •�♦�c •`�
(Sec.3097,Civ.C.].
PLAN CHECKING FEE �L� �� • •9��O
Lender's Nome !'1 Tj e �, �S rJ j O`
Pf2M1T ISSUING fEE 7
Lender's Address 0 2,0 6—8 4
I certify that I have reod this applimtion ond s�ate ihat the TaTA���
above informalion is correU.I agrce fo mmply with all County
ordinances and State laws reguloting Eimcirical wiring,and
hereby authorize ra��s ent ri .of this Coun�y to enter upon
�h e .ntio -iff � rty�for inspedion purposes. g�g REYERSE FOA EXPLAi�iATOkY lAN6UAGE
6 �7
r _ r �
Signalure of Permittee Dale
�. �
�` ��',lf � � � i ��e►��'�
r� � �� �
�3 � . --=�- � - ,- 't-'�"�..
� � ' �APPPoUVALS DATE �- � . +O�-BUIL�€R 6€CIdRFtTiON
TEN.P.POW�F PO;E I here6y offlrm tl�.or I om a.�mp!from �hc Controcro�'s
- Llcense Lc,v fcr tha following renso❑ ;Sc.fion 7031.5,
_ UN�ER�LAEVFORK Bus;nessandFrofAsslonsCod:;J:Anycitycrwuntywhich
ROUGH CON�UIT . reqafrec a/�rmtt tc eonstruct,alter,im�;ovc,demalish,
or repWr aeryr sMuaiuse, prtc:7a its I54JQl1CA� OI50 rc.
WIRING . � qulrsa ff»opplie�ant 1vr aWeh pwr3(t to fif e a signsd state-
FI7fTURRS msnt tFmt IN Is lieewse��serswscit io tHe prcvisions of the
, . - Confieeeter's Li[rfresa Lew(Ch�atx 9(commancinp wilh
- POWER AUTHORIZ�FJ $BCti6A 73v"E)of Divfslcn 3 of 1he 6usina:s cnd Profc-
UTILITY CO.NOTIfiBD sions Coafs)or fhof he ls sxsmpr th¢rolrom ard thc 6csi;
c-� for }�� oFAgtd e,rernptien. Any vicfatian of S�c/ion
PINAL �nfar nn,iro»L 7031.5 by rney a�pHf+ant(or a permif sv�jects tlie c;pli-
� conf to e cfW1 pesse(fy o?nof mor.^f5on )ivc hundre::
NOTES dollon(S50QJ.:
� - �I,es ownsr of the property will do ihc work,ard
� the siructure is nat Intc_nc�ed or otfsraa fcr sale.
, - (Sx.704i,Buslrtrss andProfe�sicns Codr: iho Ccniror
for's Ueense Law�does not opp7y to nn cv+nw of properly
� . . who 6uilds or Impvares ihsrecut, cnd who c"es> such
work hfrnself provided fhuf such tmprovemeNs orc no1
� � infend�.'or affared fer safs.If,however,�hc 6uilding or
im�rave`x�:f i,sold withln onc year o1 comple!ion,thn
� � . � own�r-bWM�rvsfl!Fave fhe 6urdon cf proving ihc!hc did
nU buNc'er lrnpreve far tFe p�rpasz o1 safc.)
I am exempt under Sec. ,
B 8 P.C.for this rc�ason
Da!e
Owner