HomeMy WebLinkAbout1636A WORtCERS'COMPENSATIONDECLARATION 78a663 APPLICATION FOR ELECTRICAL PERMIT� . ,r�
� � CE$06G(2�80) -
I hereby aFtirm that l have a certiticate ot consent to sett COUN7Y OF LOS ANGELES BUILOING AND SAFETY `J
insure,or a certifice[e of Workers'Compensallon Insunnce,oe �
e cerNfied copy thereoP(Sec.3800,Lab.�C.) - �
Yolicy No. Company ���a'W FOR APPLICANT TO FILL IN qDORESS �
❑ New Fesidential Bldgs.&Pools EACH NO. FEE •
�rtifieJ copy is hereby furnished. 1&2•Family,Sq.Ft. s = S LOCALITV
Multi-family Sq.Ft. A
Certified copy is filed with the tounty building inspection CR033 9T
depar[ment. � Residentie�Swimming Pools OWNER OR
Da[e��ApplicantL/y��� ��f�' FIRM NAME
Ou[lets:Rec._Ligh[_Sw._ MAIL
� First 20 ADDFESS 1
CERTIFICATE OP EXEMPTION FROM WORKERS' Total�No. Additional. � CI7V Td o. �
� COMPENSATION INSURANCE PLAN CMECK 6}.
(This section need not be completed iP the work involved APPLICANT �
by the permit is for one hundxed dotlars (St00)or less.) Lighting Fixtures First20 ADOFESS �
Total No. Additional � O
1 certify Ihat in the performance of the work for which this CITY Toi o. /� n
Fixed Appliances Not Over i HP ���e'��� 7�7 / F'
permit is issued,1 shall not empioy any person�n�ny manner PEFMIT - �
so us to 6ecome subject to the Wotkars'ColltpenSBtlotl LeWS. Raf1g0_H88t@f_D.W._ qPPI.ICANT y
. . . � Oven _OryBr_W.M._ ADbHESS f`�� z
Dare ApD���ant Top _FAU _W.H,._ —
� Hood_Fan _Other_ C�7Y Tai No.
ExOemlption�you Lsh ul�d.becom,er ubject to's t etiWorke sr �Disp. _Room Air Cond,__ RIEG NSUMBER�6%j Clasa �i`�i��
Compensation provisions ot the Labor Code,you must torth- power Apparatus&Large Appliances DISTRICT NO. � PROCESSED Bv
with comply with such provisions or this Dermit shall be .
deemed revoked. � . Size&Type HP,KW,KVA,or KVAR
UP to 1 Incl. �
� FINAL �
� � Over 1 to 10 Incl. OATE �O—7—�{� VALIDATION '
LICENSED CON7RACTORS DECLARATION Over iD to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 1D0 Inc. FINAL�
BV
9 (commencing with Section 7000)ot Division 3 of the Busi- Over 100 �
ness and Professions.Code,and my license is in tull force and � � . ' �
��efiect. � Services �
License Number`3�ddTJ Lic.Cless �_�� 0400 Amp.Under 600 V h ,
o 201•1000 Amp,Under 800 V '� � 6� F' �
�
Cantractos^/�/��5��� Date �/1��� Over t00D Amp.or Over 600 V ��qe p e •o j
HOME OWNER-BUILDER�GCLARATION Temp.Power,Pole&Appurtenances
Sign with One Branch Circuit � �r T, `�y r
I hereby affirm that f am exempt from the Contractor's qdditionel Sign 8rench Cirtuits '"1.���'_
License Law for the foilowing reason(Section 7031,5,Busi- 9�n�
� ness and Professions Code): - (� .(��.'—��7
� Misc.Conduits&Conductors � �
� l,as owner of the property,will do the work and the Other�See Compiete Fee SChedule)— -
� structure is not intended or offered for sele (Section �
�� 7044,Business and Pwfessions Code).
� CONSTRUCTION LENDING AOENCY . �
'� 1 hereby affirm that there is a construction lending ugency � - � ,
� fot the performance of the work for which this permit is pERM1T FEE (Sub-Totel)
issued(Sec.3097;Civ.C.). � � � �
Lender's Name PLAN CHECKING FEE (One-Fou�ih Permit Fee) �
Lenderi Address PERMIT ISSUING FEE . �7�� - ,
1 certify that]have read this application and state thet ihe TOTAL FEE � �`�
above informetion Is correcL I agree to comD�Y N'��h a�l County . . � . �
ordinances and Stete laws regulating Eleciricat wiring, and . .
hereby authorize representatives of thfa County to enter upon � . - . . �
the abave-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE � �
� .� Y/
Signature ot Yermittee Date . � �
' ' � '" ' ON'NGft-BUILDBR DECLARATION
� I hcrcby'�af6tm tl�a[1 am exempt(rom ti��Contcactor's
,. .. . . .._. . .
� -��" ��� ��� � iN5PeC7oa'S � Liccnse.Latv for the following rcason/Sectiw� i031.5.
. .APPROVAl.S� ' DATE _.SIGNATUF,E � - -- � '
, � ITusiiiess and�Frofessions'Code/:-Any ciq��o� tourtty
. ` ""� �-- - �� �7'ennP.powEFl PO�e� � � - �-- - �� � � � x•kich requtres e pennir fo constnrct, alter, irnpro��r,
� - � � � �� uNOERs�/an woFlK � .� . � - � � �_ _ �deniolish,or reparr mrp'stn�cture,prior to irr i.crucnce.
also requires thc an�f;�a,�r�o�such perm.i� ta fNe a
' . � , ; . �. rtouGHCoraoUir-„ � ` - � -� ��: � - •� srgned srarc�nc�u llrat lir is licciurd➢ursuanr to��dic
�� ., . , prorrsions oJ the Conlractor's Licerur Lak�/Chap7er 9
�... . -. . ..-- WialNc� - �� . . . , _. � /torrirr:encL�g witJi Secfion 7000J of Dirisio�r d af dic
. - . ._�. _� . � �FixTUFieS . .. . � . �. � � � Buri.ness and 1'rofc.ctiorrs Code� or that he rs exem.pt
. ..,� . ,�,..
;. . _,�
. .. . . ,.,:_. .. __.. . ._ . .. �. � -- . .. �'N�erejrom arrd 14e baais jor Jhea!legcd exemptiun.dnv
� . . _ ____ . aovre�.�uTNat�iZ[� � ' rialation oj5ccrion 7031.5 b)'mryapplitant jorepennit
' � • UTILITv CO.NOTFIEo ' . � subjects die applicant to a ci��rl perrafty ojnot nrorr tlik+r
, -�- - �- - � - �' - � ' �five�hrotdreddollars(S500J.:�� '. -
� ._ _ . . . � . FiP�A� .� �'st�S��wt �4Mt�_,, . � , , ��I,as o�cncr of thc property�sill do[hc x�ork.9nd
� � -��'- NOTEs•. � � - � ' � , - . , ; thc structure is not intended or affemd tor s�le.
� .. . ... ._. .. . . - �- � � � . . � � . . . � �lSec. 70-l�1, I3uriness ard Professrnns Code: Thc Con•
� . � . � . . �trcctor's I.iccnsc Law docs.not applp ro arr nxwer of
. . . properly x•i+o builds or improrer tPreman,ured kdro does
+ ._. ., ..,. . .
. _,_-- -_- : _.�. �.. . _._ � �__ ' ' ', . ... ,.. suck k•ork hiuuelf p�oriAed fLat rudi irnprocements
. . .,,;� ,, . . . - -a�e not inlenJed-or oJjered fur sale. If, Gowe��er,'�he
- - . �--- . - - , - �� ' � � - - ' building or i�nprorernent is sold widriir wie ��car nf
� _ . ���nPf�teon, tGe �ownervbe�ilder �i�ilf hm�e tlt�'�burJen
. .. . . . . ..... . . ',:,;i :'; , , . . _ of pro��ing that hc�did rroi build�ur improce for,ih.e
, � � �� . . �� � . �. �.. _; �� �. purposeofsalc./ �. _ . ; � . .
, 1 am exempt tmder Sec. ,
_ ., . ; _.
- i _ _ _ . __ __ � " B&P.C.for this reasoii
llatc
, - _ O�vner'
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