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HomeMy WebLinkAbout1129A (5) WORKERS'COMPENSAT10PiUECLAR1tiTION 76A663 �o�e� .qppLICATION FOR E�,.ECTRICAL PERMIT � , CE•806G I�ereby affiim th�t I have a certilicato ot consent to self insure, or a certilicate of lvorkers'Compensation Insurance,or a certified COUNTY OF L�S ANGELES � �� BUILDING AND SAFETY copy ih reo!(SPL �SJ.�b.C.) �y��' ' . . /�7L� \/�(//�� Po�icy�d.' • � Company��•� '� U FOR APPLICANT TO FILL IN JOB � ADDRESS ❑ Certified copy is here6y furnished � New Residential Bldgs.8 P EACH NO. FEE , ��Certified copy is filetl wi;h the county b�ilding inspection 1 8 2-Family,Sq.FG�� = 5 LOCALIT department DSU�� Mul[i-lamily Sq.FL nEaHEst �, R � D Residential Swimming Pools oRm�R or+ o��� oP����� /� ,q I �RTIFICATE OF EXEMPTION FROM WORKERS' � j/_ `/L ' FIRM NAME l COM?ENSATION INSURANCE Outiets:Re L'ghtFs.l_Sw.��. � ' C' qp�pqESS ' - (T(s sectlon need nat 6e Compleled Ii the work Involved by the ' / First 20 J permit Is for one hundred doUars(E100)or bae.) Total No.L�2� Addilional CITY J� Tel.NoS I certify that in the perfarmance of the work for which this permi[ ' App���K is issued,I shall no[employ any person in any manner so as to beeome subject to the Wlorkers'Compensation Lavrs. Lighting Fixtures'/ First 20 � ADDRESS . Totol No.�f�2_ �dilional CITY . Tel,No. Date Applicant � Fixed Apptiances Not Ove 1 HP PERMIT NO710E l0 APPLICANT: II, after making this CertiYicate of qpp��� � �U Exemption,you should become 5u0iect to the Lhbrkers'Compensation Range Heater� D.W.I p�ovisions of the Labor Code.you must forthwith comply with such Oven�Oryer f�W.M.� - � ADDRE55 D f � (�, �" � provisions or this permit shall be deemed rewked � Top FAU W H._ LICENSED CONTRACTORS�ECLARATION Hood�Fan __ Other_ � GTY i- � Tel.NoL 3, I�hereb affirm that I�am licensed under rwisions of Cha ter 9 � � uCeNSE oa (commencing with Section 7000)of�ivision 3 oF the Business and � Disp. ._.�Room Rir Contl. _ pEc NUMBea d l Ciass. �b Professions Code,and rny license is In full force and effect. aSTFiCr No. PROCE_ SSEp,er � Powei Apparatus 8 Large Appliances 1 �1�//� n /� Size 8 Type HP,KW,KVA,or KVAR 1 O ,\ \5.�,�J,�� h3-C Lkense Number �'L Lk.Class�- Up to 1 IncL FINAL `�' Contrac[or��7N^i � �Date�� �Over 1 to 10 Incl. DATE yq��DATION � f t� Over 10 to 50 IncL� F�N� ��� V ❑ I am exempt untler Sec. �1�1��1(`1 Over 50 to 700 Inc, gy 4J B.RP.C.lor ths reason �J Over 700 � � - � - a N Services,Sw6d.,61CC 8 Panelboards . . .. . .. . ^ Da!e: 0-200 Amp.UMer 600 V � � , � Signature . 201-1000 Amp.Under 600 V . . ., _ � . . . . �. Over 1000 Amp.or Over 600 V Exemption for Reg.Maint Elect. - � SMGIE FAMILY-- � � Temp.Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION - Sgn vdlR Ono B�anch Circuit � � - � -- �� - I hereby alfirm that 1 am exempt from iho Contractor's License Law Additlonal Slgn Brancb Circuits ' � lor the lollawing reason�Section 7037.5,Business entl Wofessions . .. , , _ ;Atle1: � I,as owner ot the property,will do ihe wo�k and the structure Msc.Contl�its 8 Contluctors _. _ . is not intended or oflered(or sale(Section�044,8usiness Other�See Campleto Fee Schedulo)_ and Professians Codc). - , �. .. ��� � 2.!F1 CONSTRUCTION LENDING AGENGY . . . . . .. . . . Y.• • • • •L , hereby affirm that there is a construction IeMing agency for the , �erformance oF the work tor which this permit is issued(Sec.3097, PERMIT.FEE _ _ (Sub-Totaq � � • � � 11,�� ;iv.C.1. . . . .. . . .. . ' PLAN CHECKING FEE • � � � 4,O O�: enders Namo p�qMIT ISSLIMG FEE - �$,2 Jr-�Fj -�Mer's Address � - � � - � � � �� - - ����that 1 ave read this apptication and state that[he above TOTAL FEE I �(�` � a¢P`��rrect.1 agree to eomply with oli County ordinances � -- � � -� � � � \ p� e9ut�fin Iectr' I winng,ond hereby authorize � t�" \��E� u y enter upon ihe aboW-mentioned � - � � �� � � � �� � -�-- " � �\1 9� y �us . SEE REVEHSE FOR EXPLANATORY LANGUACaE � - _., ` ,� �' �'`-z`/--� _ . , . �.✓ '�. j Date � . .. \i J�R � , "� .�,. _ _ - . . .. :' ' - , _. _ y...:,;.:` c: . . . �� .._.. � — :.�: ..-��_, . ,— .7�s _. i ._.... ... ._ .._._.. ._.. .__ ._.._:.... ._... . .. __ . . ..._.._.----' . � � . .._ ...._... . ... __ f � . • � - - iNsvecToas = -� - �� - �- - �- ` �Y', - - OWNER-BUILDER DECLARATION �.. . ____' . .i___ .'.. .--___APPROVALS DATE � ! SiGNA7URE � � j :, �, ' .,.. .._ ' . , . , ' ' ___-�_`-.,.i_TEN,P..POWER_POLE��� � � ��� ��. . � , � . I hereby affirm ihal I am exempt(rom the Gontractor's License � .-_______._..._. _ . .._. . . . . ., � . -.. .. . . ,. Law'for the follo�ving reason(Sectipr 703t5,8u^�iness and . i ..�• .., LNDERSLAB NJORK . .___.... .. - -�'-�-- - ' '� : tPro/essions Cotle1:�Any ei[y or tounly which requires a Pertnit . _ _.-...... ._' _' ..__ , . . . � ' �' � �FOUGH COM�U17� � � '- ' � to eorswcl,atte,improve,Gemolish,or repair any stmcNm,p�ior t.-.---�----�—--- '---1-'- . , ' '.. to ifs issuancq also rc irc5 thc applieant lor sueh percnit to li�c �P/ � VffFING � - � - - . - �- . . - ` a slgnetl sta:emen:fi15E he is licensetl pursu�nt to Ifie pmdsims '- "" --�-- "---�"-�" -- � �� • of the orfJaMor's License I.aw Cna,fer 9(canmencing wiN FiXTURES �' C � . i " � � � . , _.._._. .. . � Seetion 7000)of Divisiwi 3 0�the Business and Rclessions ��..._.' -_:_. . .---- . . . . . .' � ; ' ': , . . � PO�NER AUTHORRED ' � Codc a lhat hc is excmpt therelran aritl the�G sis 1or tbe ' _ . . , � . : afleged exemption. Any vio7ation of Sectiun 7031.0 by ceny . ._____.._._____.'.___ .. j UTILITY CO.NOTIFlED.i . � . , , ' � , . , . . applica�t fur�a pemrit suh+eets Ne applicant to a civil.penalty f-�`-�"_.� .._ ..- . .FINAC.-... _. . . rri2C7'Oft f YOtt! _� � �� of rrof morc fhan livc hundred doft;vs f5500): i � " �� � - � � ❑I,as owner of lhe property will do ihe vrork,and tl�c I -. -.._' ' .. __ '_-NOTES .' _'_" . " ' �' . . . . .. , ., , i . . . . . -. ,'.�� .� '.. . .'�. �. �.� � �. �: � , �. .. � fSee.t 7044 Bushicss.s d Profe�ions Cafa 7hc Crnfracta': 1 _.�_ ___._ _ ... ._' . _._ ..-, ._, ._ . .. . . � .._.;_, ' �... �. . . . .. . . � , , . . . . .. ,Lieensc L.�.v rloes not a,�.'Y to na owncr ot propertY who build: ; -__. _._ __._�._. ____,._..�_ .�_..-c.: . _, .. : . ,. , _ _._ ' 7rnpmvc on,a�od vrho tlocs such wwk himscif prwidci ,... - _ a s there . . . . ... _, - _., . . ,'. - ... � . . . , Iha(such improvemr.nis are not infendetl a offered for ca!e.! � . '_. _ _ ___ . . . _, �_ -. � . j- :��-�-.-- .. . � ...�. .�. - - �'-. . �. . ,� .. - .. . ,, . , . - however,the bul!d�ng or imryovemenf is soltl wi;hin one year c .............___._�_._.__. �...._ -_._ ___.._._. . . . . � �� � . .� .-canpfelion,1he owner-builtler x•i!!have the b�den ot Prov�ng th: ��- � � . . . he tlid not build or i� roro!or Ihe � � , . . qp pwpose ol sak.) � . :. , � � ' . . .. . .. , . . � ' � . , � i . . _ _ _.._ ._. ' ' _. .._ _ _ C1_" . � . . , ' . . __.. _ _ _._ 'r, . � �,_' _ � , ' _- . ' , . ' �_I am exempt under Sec: -' . , � ,_ ..- -- - -- . -_ _ . ._--- � � . �.: :. . . . ' � ''_._. __ �.. . _ -_- . .--.,.. � .'.' �. . '� ', ,; . . r.: '.. -- -------- -- -- ----- -- � . , � ,�B"8 P.C.for ihis reason� � _ , . . .._-- - ----- - -- - --_ _.. _ :. _ __'_ .; --- . , t Date I - , I � �'� . . , �� . . ' � Owner �- '- - �-- --- - . - . i .. �, ._ � .. ., . � . . . . . ... ... __. . ---- _._ .._._ _. _ . :.'.------....- -'----' ..------.._. ..--- "--._ , : . . . . . � "-- ---' - . . � „ � � . . ' , , j -'---`-- � ' i � ; . ., . - ._.. . - -_ _ - --- -- � ,/ -- - -. . .. . � . • . . � �/; i _ ' ._.' _.�'_. ... . ..' /. .