HomeMy WebLinkAbout1342A IQCRI�ON DBQARATION 76A663 ,o�a, qpp�fCATION -FOR ELECTRICAL PERMiT
I he�e6y affirm thar I have a certificote of cansent lo self CEeD6G {}
o�errifimre of Wo�kers'Compensaiio���s�.a�<e, COUNTY OF LOS ANGEIES BIIIIDING AMD SAFETY ��
�Sofee,�v�ed�op,,he,eo72-'1�5,�gQo,�iayb.-c.) ii
Poliry No.�Compa�s l�r'��h�� fpR AMUUNT TO flil IN JOfi �Q
� Certified copy is hereby furnished. New Residentiol Bldgs. ols EACH NO. FEE kDORE55 �� �,71 'L'�
�(y}�� Certified copy is filed wirh�he county buildiog inspec- �8 2-Fomily,Sq.Fc S — E tOCALI7Y QY1 �jQr'
(— tio depor ment. Mulri-family Sq.Fr, — NEAREST
Q I� �/� Residenrial Swimmm �
Daie++ G � Applicant '�✓�� �1 �Q�� � OWNFRSOR � �
F�RM NAME ��
CERTIFICATE OF EXEMPTION FROM WORKERS' Ou+lefs:Rec_li9M_Sw.�
COMPEhfSATION INSURANCE Firsr 40 OORE55 z N .1�.�r-�1 w
(TAIs a�clion ra�d rrot bs complNcd if IM work involv�d by Total Nv. Addi+ionoi CITT��(�1��� Tal.No. '-9
1ho pumit is for on�hundrrd doltmf(S100j or Iqa,j
I cerii(y fhoi in the perfarmonce of fhe work tor which�his PLAN CHECK �
ermii is issued,I shail noi em lo aP%��ANT �
p p y ony person in ony manner �i Min Fixtwes Firsf 20
so as to become su6jxl to the Workers'Compe�sation laws. 9 9 AODRESS"Z� � _
(yy/, ].. � F Total No. Addirional
Oalell.���Applicant M1L]'!1 �Q..�C�r11rh CITY . � j"Tel.Na��`�
NOTICE TO A I ANT: If, ofter making this Certificate of Fixed Appliances Not Over 1 HP PERMit _y ,.( f�
Exemption, you should 6ecome subjec� to �he Workers' Range_Hea�er_D.W._ APPUCANT r i Gj
Compensation provisions of the tobor Code,you must forth- Oven _Dryer _W.M.y. ADDRf55 '3 . �,���
with comply with such provisions or this permi�shall be Top _fAU —W.H.— ��.K�d` � C'Tel.No.'�'�-Q�
denmed ravoked. CITY
LICENSED CONTRACTORS DECLARATION Hood�_Fon _O�her_
1 hereb oNirm�hot I om licensed under P Oisp. _._.Raom Air Cond. _ LICFNSE OR
y provisions of Cho ter 9 REG.NUMeER Closs.
(mmmencing with Section 700�J of Division 3 of the Busines: power Apparatus&Larqe Appliances DISiRICT NO. PROCE3SfD BY d
ond Professions Code,and my Ilcense is in full force and effed. O'
4�.�^4r Size 8 Type H7,KW,KVA,or KVAR 4 G,'
License Number L-+✓oD ❑c.Closs� Up to i Ind. FINAL
�"
Contractor�NG���r Date�{_���Q �9P��1O���^��' DATE VALIDAiION F
❑ Over 10 to 50 Ind, FINAL L
I om exempt under Se<. Over 50 to 100 Inc BY C
Over 100 �
B.&P.C.for Ihis reason �
Date: Services,Swbd.,MCC 8 Fanelbaards �
0-200 Amp.Under 600 V
Signorure :K/1-ip00 Amp.Under 600 V
� Over 1000 Amp.o�Ovar 60p V �
Exemption for Reg.MainL Elect. '� .� `.a��i
5�NGLE FAMILY Temp.Powar Pole 8 Appw7e�ances G �
HOME OWNER�BUILOER OECLARATION Sign wi�h One 8ranch Circui� - `� �� • °G
I hereby affirm�hot I om exempt from the Contrac�o�s License qdditionol Sign&onch Circuits -�r - �
Law for the foliowing reason(Se<+ion 7D31.5,Business ond I �- c ��'�
ProSessionsCode): ���
❑ I,as owner of fhe properly, �II do ihe work ond fhe Mis<.Canduits 8 Condudors = - c. .;.', ��
struciure is no�inrended or offe�ed for sale(Sec�ion Olher(See Complele Fee SchedulaJ_ � `�L,j_ �.E
70A-0,Bvsiness ond ProFessians Code). ' � "
CONS7RUCTION LENDING AGENCY
1 here6y affirm/hat there is a<onsfru<tion lending agency for
the performance of Ihe work for which lhis permit is issued PERMI7 FEE (Su6-Total)
{Sec.3097,Civ.C.J.
PLAN CHECKING FfE
lender's Nome
PFRMIT ISSUING FEE �D �
Lender's Address
1 cerfify�hot i hove reod th�s oppliwtian ond state�hpt�he TOTAL FEE �
above informotion is ec1.I agree ro comply wirh all County
ordinonces and Store laws regularing Elecvical wiring,and
here6y authprize representotive of ihis Counly to enter upon
the bove-menrioned pr perty .o inspection purposes
54E REVERSE FOR EXPIANATORY LANGUAGE
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