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HomeMy WebLinkAbout0771A WOFiKERS'COMPENSATION DECLARATION 76As63 i0/87 l-i- - � , . �E-Boe� APPLICATION FOR ELECTRICAL PERMIT - � I+�ereby affirm that I have a certificata of consent to self insure, /-.� or a certifcate of Workers'Compensation Insurance,or a certifietl COUNTY OF LOS ANGELES BUILDING AND SAFETY COpy there�0/f�(Se�c,.�38-0�0�.Lab.CJ � Policy No. w7Lv��Compary ��'-���4��T lhs FOR APPLICANT TO F0.L IN • JOB ❑ Certified topy is here6 fumished. EACH ND. FEE AODFESs�jr�-�j 2 �j�(`�/1{LaYlT"lri 'Z� Y New Residentiat Bldgs.&Pools � 1 8 2-Famity,Sq.Ft. $ — � LOCALITY 4/f}[.YI(A,r' � �� Certifietl Copy is fileA with the count building Inspedion _ dCpe�tmfnt. �� MUlti-family Sq.F[. NEARESf �n _Z,f%$ � � 1'`� � Restdential Swimming Pools --- - �,vNER pR \�l�I�(V1�1T�.! Date Applicant � ^ � � ��� '_ �FIRMNAME J•S� IF��C(,$��I�_S . � CERiIFlCATE OF EXEMPTI ROM ERS' G/ �2 .�� � � �O MAIL Oullets:Rec.-�_Light�Sw ISG� Q�(AiL S"f"�41D � CAMPENSATION UFANCE � nDoaeSS (This sectbn nead not be completed H the work Involved by Ihe First 20 permit Is for one Aundrad dollars(5700)or less.� . To[al No.�� Additianal -J ITY n(�t���� r��� Tel.No.� ��/ �I certify that in the per(ormance of the wo�k(or which this permit - P��pM K 1��`1 G S��T,(,(�- ��(G is iswed,I shall not employ arry Pereon in any manner so os to ��become subiect to the Workers'Compensation Laws. . . Lighting Fixtures First 20' � A�DRESS (��'7 �"j(,?£,,� C.1}1t`(� (j„p Additional .. . � � Total No. �� CITY �,Jhil'�k'j Te�.No.�'i5''�pUL7 Date � Appiicant � Fned ApG��ances Not Over 1 HP .NOTICE TO APPLICANT: If, alter�makin this Certi}icate of PERt.717 ' 9 APPUCANT SA'�K�AJ IZ-���{�L(/� pr�' .Exemption,you should become Subject to the Workers'CArtpen&afion Range_Heatcr_D.W. _ provisions�ol 1he.Labor Code,you mus[lorthwith eomply with such Oven_ Dryer^ NlM.� 11b� !Qy�' ADDRESS provisions or this permit shall 6e deemed revoked �� . Top _FAU � W.H.L.. �'v ' " CITY � - - - Tel.No. � � - LICENSED CONTRACTORS DECLARA710N Hood_ Fan �Other_ I hereby etlirm that I am licensetl under provisions of Chapter 9 uCENSE OR Disp. —Room Air CAnd. _ qEG.NUMBER Clasx (commencing with Section 7000)ot Division 3 of the Business and Professions Code,ard my license is in full fome end effect. Pawer Apparatus 8 Large Appliances DISTRIC{NO. PROCESSED BV � Size 8 Type HP,KW,KUA,or KVAR p License Num6er Lia Class Up to�1 Incl. �� - FlNAL � �j . Over t to 701nc1. DATE �LIDATION Q �Contractor � - Date Over 10 to 50 Ind. U ❑ . . FlNAL _ . . . . I am exempt under Sec. Over 50 to 100 Irx. BV- . y,1 Over 700 0- 08P.C.for this rcason V! Services,Swbd.,61CC&Panetboartls - �� - � � � � � - Z � Date:� 0-200 Amp.Untler 600 V SignaNre 201=1000 Amp.Under 600 V" - � � - �� - � o�er i000 Amu.o�o�o�soo v r 0 7'7 1 P,, Exemption for Reg.Maint.Elect. ��4 ,C � � - SINGLE FAMILY � - - . Temp.Power Pole&Appurtenances , �_ . _ , ._, HOME OINNER-BUILDEF DECLARATION Sign with One Bt�nch Gircuit � � � � �.S O I hereby aflirm that I am exempt from the Contmctor's License Law qdditional Sign Branch Cirwits � - � -� r for the(ollowing reason(Section 7031.5,Business antl Professions , . o � � �,,rj Q; Code): ❑ I,as avner of the � MiSC.CAnduit5 8 Gonductars - � � � �� � � � 1,2 4^Pi 7 property,will do Ihe work and lhe structure Olher . is not inlended or olfered for sale(�ction 7044,Business _ i5ee Complete Fee Schedule)^ � and PmfesSions Code). CONSTRUCTION LENDING AGENCY � �' ' - - ' , - " I hereby affiim thal Ihere is n construction lentling agency for ihe � pertormance al ihe work for which this permit is issued ISec.3097, pERMiT FEE �� � � - �� � �(Sub-Total) �� � � � � �� Civ.C.). � /� � PLAN CHECKING FEE � - � - � Lentler's Name � �� PEFMIT ISSUING FEE Lender's Address � � I � I certify that I have mad this apPlication and state that the above_ TOTAL FEE , , . _ . . information is correct.I agree to comply with oll County ortlinanCes and State laws regulaling Electrical wiring, and hereby authorize � _ . ., _ , . _ _ _ _ � . represenlatives of this County to enter uPon Ihe above-mentioned property for ispection Durposes. � SEE REVERSE FOR El(PLANATORY LANCaUAGE. 24_.---� %-��Yl� S n u2 oV ermRtee Date C/ . ... .. ., r ,. .. . .- �. . - , . , . .., ..,. . , _ _ _ i . �. ; .., � . , . , . ._ , ._ , .. . . � , .__._ _._. _ ._ __.__� .....-.--- . ..__..__.___... .. _... _�._ _... . _.... . . _.._ ._.. _. , . ' - '� APPROVA�S � � DATE� � ��SIGNAT�[5 -- - � --- -� �-�� � � ���" �O'NNER-81JILDER DECLAqATION.', � � I hemb 3ffirm that I am�exem t from the Contracto s L�c _ _ ____ . ... . . � � �. _ ._ __ . _ . .___ _ . :. �,. .. y ' a 'ense __' TER1P:PONlER POLE� � � - - - . .. , , . --_ _.._.. ...__ .. - -- - . . .. � , ,� Law for.ihe foilowing recson(SecEid� 7031.5,��Business��ind ' �i��• �UNDCRSLA6 SYORK �. - . . .- i--�.�_ .. ;_ . _ _ " , �-�� ','. � Pro/esslons Cotle):Arry city or covnly which reqwies a�mit ; ...._____._ _..___..._.. �.� � ...to eor�7uct,al,er,imprwe,demofish,arepab a�ry shuc!ure.Piior � - ROUGH CONDUIT � -� � � " � ' �" � �� . � •� ' . �--"�fo ifs Issuance,also7eWirc;thc appficant for sucli permit to lile ,.__.__ ...___.._. . . .�_� . . . . : � , . ,WIRWG , --- ' � . ; ,, e signed st.�tr.ment Ih.�t he js licen;ed pursuanE fo the provisiwjs , �. . . ' �� "" " o/fhe ontracta's�rcense Law Ch3pter 9(commenchg w'th :__. _._. . _... .FIxTLIF7E5 _ . . . . _. , ' .. . . � ( . � i {... . .. �� � ' ' �...._.� .� 't .�. . .. •.Sectton�7000)oi Divrsion 3 W the 8usiness�antl�Prolessiaos 1'`..�'. �. ��.''�` '�� --� POWERAUTHORIZED�-. � i . .. _.. �, ._.. . �. �. �. . � � ...� .� ..� Code) ot fhat hc is'exempt fhcrc6an entlYhc'basis'for thc �--� -- --� �� - �-- �� UTIU7YGO.NOTIFIED ��1� �. I : � alleged excmptron. Any vlolation ot Seefion 7031.5 by nny � . � � applic2nl for a pemtit sub�ecfs!he epplicant�fo o civil penalry - ' �� ....___ FI�dAL. .--. - -rRICY Ol2'f'Y0J1I.. � _• ..- ��:." ; 0/rrot mae fhan fivc�undmd doUars(5500):' . � . .' . ___. .._...__ _ '._t, , , �� .�,� � - � ' � ' . . . . . � � .. r. � ��.'-� � I,as owner of Ihe property will do the work,nnd lhc � - ..'. '.___ _. .._._. _.__NUTES . _ ,. . . ' .. . ; .strucluOre is not intended or offeretl lor s�lc. ... _ :�'�'� ' � � ' �. . . � . ' (Set.7044,Qusiriess aad PrOfesSions CoCe: The Confracror'S , ._..� ' ' _'... ' _._.'.�_ . �,-.�. . . , _ , , - . _ , Ucense Law tloes nof oppry to vn ovner of propery who budds � _...____. ... __.. .. ..... ......__..... _. �_ '... . ��-��.� . ��' ,���_�.�, --, � � � " � � � a imP��'es fhercon,end who does such work himseN po�ided , ,, , . . thaf sueh improvemenh prc noQ intendcd ar oftcred!or sa(e.�If, a �..-._._ __'__. _... __. ._._____ _ . ._ _ _. .. . � . .. . . �. hou�evcr,tAe 6u!fding or improvement is sold within ane year o! . _. ._. . .. � �comA�efion,the owncr-builderwill haJe the burden olproving'�ho, i. .. ..__.. . _._ . ._._...... _ .. .._ _ _-.. ..._.... • ... , . .. . ..._._ .. , . ' � � he did not build or Lnprwe!w the pwpose o/sate.l-. . .. ,�' _ , .. � , . � _ � . .. � , , . .... __ _ .'__. ...__ '.� ' � 1. i (.,+ , . . �:: .. . � . _ . . .. '.�. . . . . � , . . . . , --�� .._ ... . .__. . . t� � `� �y''� � � � I am exempt under Sec. ._; .-� _ _..-. _- _._ , � ; . . . . .. �. . :.�_. �.. .� .. .. . . _ .._ _ . ._..- --- . - � - i ��' � � B&PC for this reason � ' ' _. i. . . i ' .: _..�,_, . � � . �.. _ . _ . . . .....--- - . . . . , - -Date - _ ' Ovmer , - '-_ �`... ... 1 .._ . . . .. . i. � . . , . .. ' �I .__.___ _ . _ ._.. _ _ . . .._ . � .,i