HomeMy WebLinkAbout1633A WORKERS'COSIPENSATIONDECLARA'IION 76A663 APPLI�ATION FOR ELECTRICAL PERMIT �
CE306G 12�80)
� hereby afrirm that I have e certificate of consent to ult COUNTY OF LOS ANGELES , BUILDING AND SAFETY
insure,or a certificate o�Workers'Compensation Insurance,or . . �
. a certlfied copy Ihereof(Sec.3800,Lab.CJ � �
vU� / ,� �.�. /) FOR APPLICANT TO FILL IN JOB
�'� Po]icY�ompan3'��r1N((/,�=—i„-�AGJFv ADDRESS �
I —T , —� NeW Res�denCial BldgE.&PoolS EACH NO. FEE
' � Cenified copy is hereby futnislted. 1&2-Family,Sq.FL S — $ LOCALITY .
� � Certified copy is filed with Ihe county building inspection Muiti-family Sq.Ft. CHO55 ST
' � depariment.y' � . Residential Swimming Pools OWNER OR
.Z`I�'II �T I e..c FIRM NAME
Date ApD��cant -�� Outlets:Rec.�ight_Sw._ MA�� .�
- First 20 ADDHESS
� �CERTIPICATE OI'EXE�7PTION FROM WORKERS' .Total No.� Additional CITY i o. }
� - CO.LIPENSATION iNSURANCE � � a
� . PLAN CNECK O
(This section need not be completed it the work involved � - APPLICANT V
� by the permit is for one hundred doilus (5100)or lessJ Lighting Fixwres First 20� qopaESs �
� Total No.� Additional 0
1 certify th�t in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY 7ei No. U
permit is issued,1 shall not employ ony ptrson In any manner PERMIT W
so as fo become su6ject to the Wnrkers'Compensation L:nvs. flange__Heater_�.W._ APPLICAN I d
� � Oven _Dryer_W,M._ ADORES� y .
Top _FAU _W.H._ Z
Date Applicant dTV Tel No
� Hood�Fan _Other_
NOTICE TO ANFLICANT:If,after making�his Certificate of Disp. _Room Air Cond._ LICENSE O �
Exemption, 1'ou should become subject to the Workcrs' REG.NUMBERoL.3IR� Class
� Compensation provisions of Ihe Labor Code,you must forth- power Appa�atus&Larpe Appliances DISTRIC7 NO. PROCESSED BY
. with comply with such provisfons or this permit shail be Size&Type HP,KW,KVA,or KVA � /�(�
deemed revoked. Up to i Inel. �v "—' ������
FINAL
, - Ovef 1 t0101nG1. OATE � P {�n
'� LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. O q p�� VALIDATION
I hereby affirm that 1 nm Iicensed under provisions of Chapter Over 50 to 100 Inc. BY AL �
9 (rnmmencing with Section 7000)of D�vision 3 of the Busi- Over 100 �
� ness and Professions.Code,and my license is in full torce and �
effect. � Services .
License Numbe�3�qg4 Lic.Class C��Q � 0-200 Amp.Under 600 V � . �
201d000 Amp.Undsr 600 V
Contract�Vl���s�� /�Bj�/��� - Over 1000 Amp,or Over 600 V
� HOME ONNI:R-BUILDER DECLARATION Temp.Power Pole&Appurtenances .
1 hereby affirm that ] am exempt from the Contractor's Sign with One Branth CirCuit ' �
License Law for the fol�owing reason(Section 7031.5,Busi• Additional Sign Branch Circuits
�. ness and rrofessions code): � '?'��6�.3 A
'� � � Misa Conduits&Conductors � �
. � t, as owner of the property,wili do the work and the Other(See COmplete Fee Schedulel—. � �r• •�• • �2
structuro is not intended or offered for sale (Sectian �
7044,Husiness and Vrofessions Code). � � • • � Q 9�
CONSTRUCTION LENDING AOENCY -
� 1 hereby atfirm that there is a construc[ion lending vgency . • • • � Q 9 Q�
. for [he Pe�formance of the work for which [his permit is pERMIT FEE ISub�Total) �
issued(Sec.3097,c��.c.�. _ 0 2 2 3—8 2
Lender's Name PLAN CNECKING FEE IOne-Pour[h Permit Fee) � �
Lender's Address PERMIT lSSUING FEE �
. 1 ttrtify that I have read this applicetion and state that the TOTAL FEE � . .
' above information is cotrect.1 agree to complY with ali County
ordinances and S[ate laws regulating Eiectrical wiring, und �dV��h�nn��' _ � .
� hereby authorize representatives of this County to en[er uPon � 1���
� the nb ve-mention d properry for inspection purposes. � �
SF.E'RPVERSE i�OR E%PLANATORY 6ANCUAGE
� /d,��`{�/
Signature of ermittee Uate
:�
� � � � � � � � o����tr-i3u�i_i�ri:ueci_�r�,�r�ou
. - ... � - - 1 hu�ehy ailirm P:c�[1 am esemp[f[urn�he Contractor's
� � - AF. ROV,4LS onre irdsWe.cToi;•S. � . . - ��� � Licci� la•r fur U�c follu��ing res�un(Secrint: 7031.5,
.. ' {'' - ;i,:�ATunE � . . . . . . . �P.r,:.n�-cs�v,r1 Frr��rsiaar Cod.J� drr) ein�--or coiu;t}•
� -... ...• .. . TE�.1°.POY�F�FOLE - � � � ' 1:":iC71 Y�'if!l�YiF.C (�c'!1!]f7 7D CO�tPtn�cf, CI7.^r. tnr/ir�i�r.
' � . ,. �GNDEFi�5�A6 wORY _ . .. . . . � � rcn:�rLsh or ry�cir crp stntctur..l�rios tti irs i.rsnar�ce.
. r�so styinrrs drr r,p��Gccnt fur such permit to f:lc n
. _ . . ." nOUGH cO��oUt-`�- - �� � - si;;r,cd sratrni�,ant d:c1 !ir is liccr�rcd purs�iart «�'ti:r
- I - _. � . ; prnrisior�c r.J'dre Cur+tractnr's License La�:�(CiraP(er 9
. .- . ' . ' . .N'If11NG . � � � -
. , . . .-(err`:n;e�t;i�r.; �cide S�•eriorr 7000J <e7.Dirisiurt 3 oJ fhe
, _ - . . FitiT�ilRES. - � _���. - � - . � _ Um-ir.ces and fYofessiarrs CodeJ or titat he is etentyr
. _ ... . �6erifrun�ced!he h,�"ir fnr th.e a!li;pcd exernpliurt.AnV
' . .. . _ . •�POLtER:.uT9iOn1ZeD . rivlu'ior.of Sr:Rw:7031.5 61'r.r�v cn,nfican7 forp perur.'t
UTILITY CQ NOTIf1--❑ . .s:�liici�ts liic u�(+licartt lo a ciri!/>ennfl}�oj�rnt nlarC fl�c�r
� -� .-� - ' � � ' �� �7 � � fi��cl::r.;d�c,+dolrars($SOril.:
_ _ FINAL - �I:�G3_6�L r2C41� - �❑l,a:�o���ncc of ihC pcoport}'��.il;do Ihe��oc6.auS
' , �� . tl�.c structurc i.c not intcndc�I ur oticred for salc.
. � . . . .. �� NOTES . � � � � � � . fS='c. iOJ�. P.iesin.ss and Profese�iur;s CuJ_: TLc Can..
� � � ... � . . . trc�'inrJ L.ie^+rse Lcrr doc.c ito�epP1r�tn mt o�rne�i�J
. . propert}� �:l:u h,uilds or improi'r.r ll�ercon.an:1�rHo doe.c
-. . . . � � ,r'rc1i �rrrl: L(rru'elf yrorided tl:at sudr in:;�rorerner�ls
, . .. , . . are not intend,°d or affe�cd(ur rafc. !f, Imwrrer. thc
. . � . . . . . . . ��, . . . ' � hui.'d;r.�• ar ir�:�>,•orc�(�:nf ir sold �vitGirt onc rcc� af
- . . . , ront�d�lin�r. 1N� mc+le�r-hailder �rilt Lm'c thr htrrdcn
.. .. . . . .. . . , � . , �nf f��'uri:rr 1l:at Ac did, i�n[ buiid or imprnre fur thc
- . . F'vr;os^�;fsalc.l . � . . . , �
. . . . . . � . ._._- � I,un escmpt undcr-Scc. ,
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$fi P.C.Sor Hii�rca.on
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