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HomeMy WebLinkAbout1278A WORKERS'COMPENSATION DECLARATION 76A663 ,o�e, qppLICATiON FOR ELECTRICAL PERMIT {� GE-806G I hereby aflirm that I have a certiticate of consent to self insure. �� or a certificate of Workers'Compensation Insurance,or a certiGed COUNTY OF LOS ANGELES BUILDING AND SAFETY copy the; t(Sec 3800.La � ����y��.� �` Policy No. ComPany � '"�� FOR APPLICAN7 TO F1LL IN ' - JOB� - .Q•.Cer[ilied copy is herehy fumishetl. , �FACH NO. . FEE AOORESS _ . New Residential Bidgs.8 Pools `� Certified�copy is liled with ihe coun[y building inSCection 1&2-Family,Sq.FL $ — S LOCALITV � NEAREST � depar nt. � - � ��^/ Multi•family Sq.Ft. - CROSS S7. Date Applicant�"{ �i,e-�.� Residenti�l Swimming Pools � m.�Eq oq r y FIRM NAME .C IFI E OF EXEMPTION FROM WORKEflS' � - ' r Mni� - � � . COMPENSATION INSUFANCE . Oullcls�.Fec�l.i9ht i...Sw.'��' �� - '�lO' aoDRESS � Frst 20 S .(Thls section need not be wmpletad I�tM xrork invWved by the Total No.� Additional CITY Tel.No. permll ia lor ona hundred doikn(5100)a leas.) I certify that in ihe perlormance of the work for,which this-permit . , PVN cnE �� is issued,I shall not employ any person in arry manner so as to � A���� . become su6ject to the Workers'Compensation Laws. L'ghting Fixtures First 20 � � � ADORESS �- ' � � '� TotalNo.� Additional CITY - �� � � - TeI.No. Daee ApWicant Fixed Appliances Not Over 1 HP PEF.Mir NOTICE TO APPLICAN7; If, after. making this .Certilicala of �. FPPLICAN7 � L Exemption,you sFwuld become su6ject to the Workers'Compensation Ran9e_Heater_D.W. _ � pmvisions ot the Labor Code,you must forthwith comply with such Oven_Dryer_ W.M._ AODRESS � Drovisions or this permit shall be deemed revoked. � _ Top ,._FAU ^ W.H._._ CITY � 7e1.No. �L�CENSED CONTRACTORS�EGLARATION � Hood_Fan _ Other_ .I hereby affirm ihat I am licensed under provisions o(Chap;er 8 LICENSE OR (commencing with Section 7000)ol Divisbn 3 of the Business and � Disp. —Room Air Cond. _ aEc:ruurdspa �s� - P/O�e35i0115 COtle,e�d fny IiCe�Se i5 in full fo�Ce and eflect. DISTPICT NO. PROGESSEO BV � , Pwrer Apparatus 8 Lerge Appliances �� _ a1 /'�/ Size 8 Type NP,KW,KUA,or KVAR ( Q LicenseNumber�tl�3�.3' Lic.Class_S..k— -�� � � � /� - -- - � O --�- � � � Up to 1 Incl. FINAL / . t1' t,,.-�(�(� Over 7 to 10 Incl, �A� �� � " 4AL1DAT10N a Contractor�C�� DateS�!J��1L�/ ._.. . . . . -. . _ . . .. _ O ❑ . ' J _� Over 10 to 50 Incl. FINAL I am exempt under Sec. � . Over 50 to 100 Inc. gy V B.&P.C.for this reason Over 100 d' . � � Services,Swbd.,MCC 8 Panelboards � � � � � -�� � - �� - - ,Z - Date: 0-200 Amp.Under 600 V '�" Signature � 201-1000 Amp:Under 600 V - -� �- �� � - ❑ _ . .. .._ . . ., ... , . Over 1000 AmP.or Over 6D0 V . . . .. . . .. Exemplion tor Reg.Maint Elect. ._. ..__ ., _... �� - � - SINGLE FAMILY - � ' Temp.Power Pole&Appurtenances HOME OWNER-BUIL�ER�ECIARA?ION Sign with One 8ranch Circuil � � � � � - � � � � 1 herehy alfirm that I am exempt Irom the Con[ractor's License Law for the foltowing�eason(Section 7031.5,Business and Protessions �� Additionat Sign.Branch Circuits . . _ . .. _ , Code): � Misa Conduits R Contluctors - ��� - � � � � I,as owner of the property,will do the work and the structuie Other(See Complete Fee Schedule)_ � is not intendetl or ollered lor sale(Section 7044,Business � - and Professions Cotle). � - � �� - � CONSTRUCTION LENDING AGENCY - � - - .- .. . �� L'],£j(� ' I hereby affirm that there is a construction lentlirg agency lor the � � perlormance of ihe work for which this permit is issued(Sec.3097,.- pERMIT FEE - - - - �(Subdotal) � � � . �� - � � .' • �`2 Civ.C.�. - .PLAN CHECKING FEE _ . . .. �, , . _ . . � Lender's Name I • �2 2 Jc� PERMIT ISSUING FEE Lender's Address . • ° •2 2 Jr O F� I certify that I have read lhis appliwtion and s[ata that the above TOTAL FEE� ' • . ._ .. _. . . . . information is wrrect I agree to comply with all County ordinances �� Q 9�� �8�7 and State taws regulatinc�Electrical wirin9,and hereby authorize , representatives o(fhis Cqunry to ente�upon the ahove-mentioned �� � �� -� �. � "' " - � - � � � � - � '-� - - properry lor inspection Durposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . � . .. _.. . _ _ _. . _ . . . .... .. .. . . . . Signa�' r tee�- . Dat � . - � . , , .. ,. _. _. ,. . . . ; ; ; . ,�_ . . �._. . =. - . � ;��� , , . ' : .: '� , . , �_. _ _ . , ..;u: _ . , . . 1 _ , . f , . .. __ _---_ ----.._._ __._. _.._ .._ ._ .. ... _ , . +, � - . -, � - _ _ ._ ' . . _ � �' � v (� � � �.. - APPROVALS -� �� - -DATE� IPI5PEC70R5 '' _ _ . _ ' � - -�� =�-=.. OWNER=BUILOER�ECLARATIUN".� - — -- 1 . +..� _ ' � s�criaTune -�: � '��� TE�1P.PO�VER�POLE-��� � - , ,- - ' � - ' I hereby aftirm that I am exempt Irom�the Conlraclor'S Ueense ; -------- - ---- �' ' � - " - - � � � � Lavi for the tollowin9 reason fSection 7037.5,�Business and ; � :.,�: > ..LINOERSlAB VJpRK �. -- . . -..__t.--..� .. _ . .� � . . ' � Profession.^,Cotic1:A ci a easrt which � � .. ..._� .� .- � RJUGH CO^JOUIT ' ' . . ... . � . .- .. . to'tons�.+Ci,a1M;Imp O�e,demo�sh, Y..`mi a,ry st'rucNm,p�a. or rop � :�,�,. ..�-"_\ � . `" ,•� ��� to i!s issuance,`a�so requrres the appl�c�anf hu sJch pdrinif to tile i •.. - � .._ ,-_. ,\ _ , c .� �. � WIRING , �� � �'; �-� ,� ; ;�j ; � . . � a signed statement flnat he is(icen5ecf pur5uont to tl�e O��sions � -������\ � -- - --- �._.. _„ � �, � 07 fhe Cor�tractor's�Lkense Law�(Chaptei 9(commencing with ' �IHFURES� .� '. -...... . _ f •i�. .1'� .- ' , o. � '�,�' � '.,� ..i,, . �� ' �Secfion 70001 af Orv7sion�3 of Ne Busihess'end Pro!essions �� �"��`- �--"-- - -' �POWEF AUTHORIZE� �� � � -�� ��, ��� � � � ; Code1 a th�i'he�is exempt�thercfrom wcf the'G�sis foi'!be i � � ,.-.. �. .-'..__.�...- `�-���- 'UTRITY CO.NOTIfIED' � . � T'P nY 031.5 by�arry i alre ea exG tion. A violation of section 7 i , , � applicant lor a permif subjects 1he npplicant�fo'a��civil penafly �_..�__. . _1_,--__ .._ .FINAL._. .______j:y1tL'Y OlT 1�YOfll ' .,.,. '- � of rrot moro lhan(ivc h�mdred tlWfars(S500J.. . � . � -� .. . , �. . '",1_ ._ .' ' � ❑I,as Owner of lhe preperty r�ill do ihe yrork.2nd ihc , .-_ _.. ._ . . _NOTES. . ..._. . - , � ., .. ,. . p --st�uc�ure is not Intended Or offered for sale� " + `,-,` `-.-'.. t. . ` `_• ��I � __. . � �� - _�„�• _.,,,J .. i . , fSec.7044,Business and Pmfessi0ns Code: The Can6acror's ;.— �s .. .�_ _'.� , . . .. . . � •�` �•. .��' ,�. . � � "._. � . � �..._ � � ' , Or improves't ecereon an�ho C ss�uch�vork hrmse��o r�c�d _ .__.._.__.. ....:.. � _.. ___. . pr� " ,.4 !'..+. ' ..��•, . - . • --. -.: I T�iow�Ih16�uvd enb�pnwc he�(dIh doµf�'�etl!w s�lc.If, , . ... ._. � ._ . . � g n mc ycar of _«� L. , . . , , eomp e on, �e avner-ui�r�n ave e'bNden of prowng mat - �.,_ � . � - , � . ' he dtl not 6vild w imprave fa the pwposc ol safeJ ' ' ,, , . � � .. .y ,.. , � ; � ;� .. . . . , . -. �_ ___._..'__ ' -_- _ �. :.' 't . .. . ._'_ . _.. _ 1 � i � ,,., - . �� � , �� � ,��.. '3'.r :� . , � ,� .. :_ __ .. __. .. .. _. . . _�..../ _ . . .. � . i . . � . . . . � t . _--- I - `F,I am bxeme�under Seb - ' �� i - � .. � __ �:, � . - - _ - - „��; �. . ��� � ' � ..- ��B&P.C.far this reason - . � �� "�. ' �_` ' �--- ' - • _ . , . .� � � _ -_- .. _ _. .--- ... . : -� �Date__.....___ _. . . . . , . �� .. . ... . , , ,_ .- - -. ... .. �• - . . . . � �. . . ,.� . t.-) � . . _ � . . �, Owner . , . .�i. . , ... ^ ,_ � . . , . . :-: �- ,� � . -.., • .,r�� �� .. � �:. ., . ,... ' .. �. . ... � _..� . � . .� , ._. _. _.. --� -�------ . �-- � �� i �� .. + ..., ., : :- ,: :: ._ .. . , , i . . . ---- � ...__...---- --- --___.. __._-�-------- � - ...,. . _ .. ... . ,,. t . . . . �. .. � .�. . � .. __._ .._.__.�_. .---�---�---...--'--'� ---`- � ,.. .� . . . . , . . ._..__.__---., . . �.,, .. . . �. .. �,�. . . .,, .,_, �r.�.. . - , -_._ _.__) � i _ _�. . . .._I_...___.�, - . ,- - , t . , . _. . _ _.. ._._'_-_.__'__ .""" '_"—' .•� . .. � , .. .. ....._" . . . � . � _. ..,., , ...'__ .�_. _. . _ _.._ __'_'_ _.__: �-.�' > .��.1 . � . i �.. . . � . � ... . �., . ., .... � �., . . .`>>'�.� � E:` --._ . �.�.�-��.�' .�,. 1� 1 . 4 '