HomeMy WebLinkAbout0714A WORKERS'COMPENSATIONDECLARATION � �o�e� qpp��CAT10N FOR ELECTRICAL PERMIT �
I hereby offlrm thot I have a cenificale af conse o se CE� �
ins�re,or a teniFico�e of Workers'Compensation f�rsu�a;c� COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certitied copy�hereof(Sec.3800,Lab.C.) l,/
acy No. Compony FOR AMIICANt TO illl IN DDRE55 I �lJ C4'{.�� %CH�uGy. �
Cer�ified copy is hereby furnish d. New Residenfiol Bldgs.8 Pools EACH NO. FEE
�� 1 8 2-Famil q. E — E LOCALITY ,'� � �.
�/r Cer�ified mpy is filed wifh 1 mu y huilding inspec- Y•5 F�. _ �d""<<"v'� � .
/" lion deparlment. Mohi-fomily Sq.FL NEnREST p
�y�,� �Q� f� Residen�iol Swimming Pools OWNER OR 1�N �� �
DateS�.lJ l Ap licant �`-�
p FIRM NAME � f'-�_L
CERTIFICATE OF EXE TION FROM W RKERS' �D / �U �S MAiI
COMPENSATION'ItJSU Outlets:Rec_Light_Sw._ �� .�� r. qDDrtEss `— P��Cl1nJ�
Thb��ctien n��d net b�com Ih•d if rh�werk inrelwd h �q First 20
t P Y Tatal Na.�l_ Additionol .3'� CITY ��� Tel.No.
fh�p�rmit fs fer o��hund��d dollan(f100)or I�ss.)
I certify that in the pertormo f ihe work for which Ihis qppN�C4N7K
permit is issued,I shall nol e ploy ny person in ony manner .
so as to become subject to�� Work i Compensotion Laws. Lighfing Fixtures Firsl 20 � `5 ADDRESS
�O-(�'�,l Total No.� Addirionat
pote �4 applic nt C�TY Tel.No.
NOTICE TO APPLI� T: If, oHer mc �n lhis Cerlificale of Fiaed Applionces No�Over 1 HP PERnvi /�II ,( .�
� 9 Ran e_Hea�ar_D.W._ AFRICAN7 �l_A1 r c ��rcG .�L Z.
Exemplion, you sho� � jecf to fhe Workers' 9
Compensaiion provisions of the La6ar Code,you must forlh- Oven _�Dryer _W.M.— ADDRESS 2 � � ���
with camply with such provisions or this permil sholl be Top —FAU —W.H.—
deemed revoked. CITY � ��-��„c.� Tel.N ��q��
IICENSED CONTRACTORS DECLARATION Hood _Fon _Othe�_
���N�� u3z9n—�
�hereby afGrm Ihat I om Ilcensed under provisions of Choprer 9 Disp. _Room Air Cond. _ REG.NUMBER Class.C/� }
(<ommencing with Section 7000)of Diviston 3 of the Business DISTRICT NO. OCE55 BY [1
and Professions Code,ond my license is in full forca and effect. P�""er Apporotus 8 Large Appl�ances � , U
�-7 �7 C_,b Size&Type HP,KW,KVA,or KVAR
License Number �;2��� 1 Lia Class Up to I IncL FINAL �
Over 1 to 101nc1. DATE/D�'{! � VAIIDATION �
Confrottor pole � U
❑ Over 10 to 50 Incl. FINAL W
I om exempt under Sec. Over 50 to 100 Inc. BY �
B.BP.C.for t i eoson Over�00 Z
1 n_�q• ��.ti(�� � Servites,Swbd.,MCC 8 Panelboards , .r O 7�,(A A
- � � t 0-200 Amp.Under 60p V
S;�/\,�n�ra , 1 � A�._ 201-1000 Amp.Under 600 V �;� . • . .�•2
` Over 1000 Amp.or Over 600 V
� Exempl�Orr-for-Rec�Maint.Elecr. � • ;(z']rj
$INGLE FAMILY Temp.Power Pole 8 Appurfenances
HOME OWNER-BUILDER DECLARATION Sign wilh One 8ranch Circuil •�• •J G'7 5"
I hereby offirm that I om exemp�irom the Contractor's License Addi�ional Si n Branch Circuits
law for the following reason(Section 7031.5,Business and 9 � G.� %-�J
Professions Cade):
❑ I,as owner of the o ert M;sc,Conduits 8 Conductors .
pr p y,will do the work and the Olher(See Complete Fee Schedule)_ ►
struclure is nol iniended or offered for sale(Seclion
7044,Business and Profestions Code). �
� CONSTRUCTION LENOING AGENCY
I hereby atiirm thai there is a conslruclion lending agency lor
the performonce of Ihe work for which rhis permii is issued PERMIT FEE _ (Sub-Total) �
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
tender's Nome
PERMIT ISSUING FEE � •
Lender's Address �
I certify thar I have read fhiz applica�ion and s�aie ihai the TOTAL FEE 3G.�
obov in(ormalion is correci.I ogree to comply with all County
or nan es and State lows regulating Electriml wiring,and
h p t 'ze represeNa�ives of ihis County fo enter upon � �
�h ob e lone properly for inspection purposes.
��J 1D^,$_�'/ SEE REVERSE FOR EXPIANATORY IANGUAGE
D
of Permitlee Doie
.._ _ . . . i. . .' . �-,j �i . ,
�.._.
� -�� --� �-- -�- -��-� -- — -�-' ' �- " � OVJNeR-BUILDER DEGLARATION
� APP�'OVF�LS . DATE �•�rc�.i a a, . . , . .. , �
. . .., .. � __.. .__S�FNAiURF _. ____. ___ _ __ . ..
� � � - � lEh',P.POWEF,FOLE, �- � - ---- - - ' � � � � � I horeby affirm nc�i 1 am ezemp'from the Contrac�cr's
�, - . . , . . � .. . . _._ _ __ . ._ � �' . I � _.,License� law for Ihe following reason (Sedion 7C34,5,
� -� - --�- -- �-� �" UNDERSCA9 VJOP.K � �� - �, . � ' Buslness and Prefer.lons Code)�Any cl�y or counly which,
�-- - � -- --r - �� ROUGH COD:D"J'i". . . ' ��� - . . aqvlres o p m71 fc cansiru ,olto„1.iprove demaU,h.
r cr rf
-or repC�r uny afruNvrc,prbr to Ita issuance, also rr�
� - � - � �-- � VJI�ING �' ,�� � . , qvlra:fhe appllcont forsvch permlf io!i!e a 9gned s�a�e�
, . ,�. � • -� - - ' . menf Ihc�he fs lltonsed pursuanf ie fhe provfsion:of tho
; . . ___ . .' FIXTVFES.._. " .. .'. , �. ..%_ (•�., � ., .
-- �•(`� , Conlroctor's Lltense Law(Chop>er 9(commencing wlfh
. . _. . .. ... .
. . . _� . _ FOLVER AUTNOR2E0 � '' . � - -� �-' � - � Sedion 7u00)o!Divislon?ef fhe BusMess and Proles�
�. � - :lons CodoJ cr Iba!ho Is exempt fhercirom and the Sasls
• __ __ U71LIN CO.NOTIFIE� - � � � fo� Ite alfoged esempHon. Any vlola6o� ol Sa:tron
�. �. ,. : -�•-.
� FlNA! ' �+ � � --'-- -�' ' ' - � ' � ' ' .703L5 by any eppli<nnf for a permlt subjects fhn appli-
'_ _ ......_._ . .- �. C nl:r nn�rorsf ��'���� '�� , �, � cunl fo a dvl!periofty otnot moro IBon (tvc hundred
' NO7FS � � ' ' " � � dollcrs(550�).r , � ' �
' � -"-�" - - � ' ' � ' '��' � � , ❑I,aa owner cf tho property wi�l do the work,and
� " � � � the struttoro is nct intended o'offe�ed for sale. �
. ,�� j ,_ . ' :. .... . , �(Soc.i6l�,Auslnoss and Fro/vss7ons Codr ihe Confrar
_ - � ' - - ' - for's Llcense Low docs not vpply to on ownvr ol property
, . � . � � , � � � � � , wbo L-u11ds o��lmptovos lharpon, ond who do�s s�ch
� � - - -- - �- - -� - - - -�' � -� � � - work Mlrnia(I provldad fhal suth Improvemenfs are no�
� ��- -�, � . �. ... :� � � �� ----�-----�-- - �"-" ' - - ' ' � inlended ar oNcrad for sola.Il,however,fhe 6Wlding or
. . ._... .. _ . .... _... .. � .
� � �� Improvr^icnt Is sold wlihln one yec�of complefion,tne
t � �-. � ' � ' owner=6ulldcrwqlhavctBe6urdenafpravingthc{hedid
, __ �_�1 _ � -- � � � " ' �' nor,bvlld or lmprove for fha purposc o/solc.)
� . . � � .. . -� --�� --- � -� - ' . .. . I am exempl under Sec. .
, _ _._ ._ �. . , , . . . �
.
` � . ., � � ... ' .. -6 E P.C.fa�his roosor.
�..<S_:.. , .,
�,..�_'. . �_ .. � . . _ ._ . . _..__. ' � ., ' . _ ..... __ . _ _. _ _ , , .
- - -. .. . __. � . . . ... � � . Da�e . . . ��
i _ , , . . . . �.
Owner
� ' � ---. ..- 1 -. ... ---- .. . - -- .._ ...._. , .
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