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HomeMy WebLinkAbout1289A WORKERS'COMPENSATION DECIARATION 76A663 10/BI qpp��CqTION FOR ELECTRICAL PERMIT ' � I here6y alfirnTlhot I have a cerlifimle of conseN fo self CE-806G insure,or a cerrficate of Workers'Compensat�on Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy ihereof(Sec.3800,Lab.C.) acy No. Campany FOR A/PIICANT TO Fllt IN !OB /�/� S�p�T"E •��/ '� CeA��ed copy is hereby furnished. New Residential Bldqs.8 Pools EnCH NO. FEE /+ooRE55E� � Cerllfied co s filed wiih ihe co�u�nyt 6u'Idin inspec- 1 8 2-Fomily,Sq.FI. E — E (OCALITY���lv(lfl� PY� l'J � lion depanmeN. Sf44:�7q- Multi-fomily Sq.Ft, fROSS ST.Wi9'��e'�//�!�(G����� Dale�Appliconl �"' Residenfiol Swimming Pools OWNER OR CERTIFICA E OF EXEMPTION FROM WORKERS G+ Z F�M NAME F �'� GOMPENSATION INSURANCE Ouilets:Rec.�_light�Sw.� ApDRE55 This t�eflon nNd nof b�tom 1�»d i(�h•woek Inrolv.d b ry First 2p S � p Y Total No.� 8 Additional — CITY Tal.No. }h�p�rmil b for en�hundr�d dallars({I00)or I��s.) Plqrl CHECK I certify ihal in the performance of Ihe work for which this qpptlCnt�i permit is issued,I shall nol empl0y ony person in any manner � so as to become subjeci to Ihe Workers'Campensation Lows. Lighting Fixtures First 20 ADDRE55 Totai No. Additiona� 4PPI'Can' � � l � qTY Tet.No. Date ` — Fiaed Appliances No�Over 1 HP p[eMii NOTIfE TO APPIICANT: If, aile� makin9 this Certificare of ' qPptICANT Exemption, you should become subjetl to Ihe Workeri Range_Heater_D.W._ Compenwtion provisions of Ihe lobor Code,you mvst forth- Oven ,Dryer —W.M.� ADDRESS y . with comply with suth provisions or ihis permit shall be 7op _FAU —W.H.— CIN '��`"fT � • Tel.N � �' �� deemed revoked � Hood _Fan _Other— . LICENSED CONTRACTORS OECIARATION uCENSE Oa 2 1 Disp. _Room Air Cond. - REG.NUM&ER �au•�1�^ I here6y affirm that I am licensed under provisions of Chopter 9 y: (commencing wiih SeU�on 7000)of pivislon 3 of the Business DISTRICT NO.� V OCE BY 0.: Power Apparotus 8 Large Appliances � and Professions Code,and my license is in full force and eHect. J 2 j4-S I"V Size&Type HP,KW,KVA,or KVAR / � p�1 U^ Litense Number� Lic Class C—�n' � FINAL a f4owAAVS '�RY�CR 1nA}NTtPY-N(.E-' �--� Uptol Incl. pATE v-� ti���� O p,p� � ��.t,�� e Over 1 to 10 Ind. r VAUDATION U Controcto�� �� Date Over 10 to 50 Ind. W ❑ FINAI I am exempt under Sec. Over 50 l0 100 Int. BY n" B.BP.C.for this reason Over 100 Z Date: Servi es Swbd.,MCC 8 Panelboards ��� ► l:� G��� ���00 Amp.Under 600 V Siqnalur 201-1000 Amp.Under 600 V � �. • . • •`� . ❑ Over 1000 Amp.or Over G0p V �.�'�'1 Exemption ior Reg.Maint.Elecl. O O � e •5(a�p SINGLE FAMILY Temp.Power Pole 8 Appurtenonces � � � � Q � r= HOME OWNER-BUIIDER DECLARATION �G•." Sign with One Bronch Circuit I hereby affi�m tha�I am exempt from tha Conhacror i License pdditional$ign Branch Circuits I Q� (�—�'f � Low for the following reoson ISection 7031.5,Bustness and Profess�ons Code): � ❑ I,oz owner of the property,will do the work and 1he Misc.Conduirs 8 ConduUors � structure is not intended or otfered for sale(Section Other(See Complete fae Sched�le)_ � � 7044,Business and Professions Codej. CONSTRUCiION LENDING AGENCY � I here6y affirm thot Ihere is a tonshuction lending ogenq for � Ihe performance of Ihe work for which Ihis permit is issued pERMIT FEE � (Sub•To�al) S (Sec.3097.Civ.C.).���� . PLAN CHECKWG FEE f� lender i Name �'� PERMIT ISSUING FEE � �pti lender's Address - O � � I cenify thoe I have read Ihis appticarion and stafe thot the TOTAL FEE /� �>?i/� above info�mafion is mrrecL I agree lo comply with oll Counly �(y`�f�� ordinonces and Slafe laws regulating Electricol wiring,and � hereby thorize re r enta� es o(this County ta enter upon �/i . ���o� e r inspec�ion purposes. SEE REVERSE FOR E%PLANATORY IANGUAGE , �' !�d-�'�.S_�" Signo�ure of Pe�mitlee Date � � . . .. .. ,�- �. . �,., ...,.��:�:.. , , �,... . � . . �..- � . � .. . . ... . .,.. _.... . . .. :!". . . . ,_ � . - - -- --- `y ,. -,._.f _._._ .___.. . LDER6ECLARATION - .- �.. . _ .. .._. . . .. . .� o,aa�OVntS �_--,OATe . . .. OWNER-BUI . . � . � . . . : . � � .._...._..gIGNATURE - . ._ .. ..__"_ .-.-._-.' .__. . . _ __ ... , - . . . . . icM�'.FpINER POLE ...� '- . ��-_- . ,- �..- . .---;; : -.. . ..�' '�-'.... .�...� ' .�. I her�by affirm�iha•I bm exarnpl}rom the Conrrac�or's � �... ,-- .., ,,-��-.. �. . ..Licenzo.Lav. {or ff�o (allowing reo,on (Soction7037.3. ... .._.. . _., .. _....__.. .. . _...__-__.. . . . ' . �- - --- ' �-� -"� ---� U�.bCRSLA9YJ0^nY,' � ' � CuzlttP.sscndFrole,-slonsCode):Anycltynrcounfywhlcb - � .. , ,,. .. � ._ . __ .__ . � ' - � �- - �---- ROL'GH�GONDUIT�- , {��__. ' -�� �. - - ���:� �,� : � requtros o permM fo construcf,ollar,lmprove,d3molish, � �� � � - -�-� � � --�-or ropct:anysfrucfuro,prlor}e%/s��lssuancs,�oJso re� ---�-�' W{RMC--. ....- �. .. � '�. .�. � .. -.. . qWrosfhooppllcansiorauchpermittoflfoas�gnedsfalo� : � fIXTUR@5_ .. � ' '. ;' �-. � �� � . .�' -���:. .. �� '- , ed purs he provlslons oi fhe . _.__ . _ . __- _ , . . . . ' ' mentlhof ho Is Ifccns uant}o i �- - � � ,Cpnffacler's Llcense Law(Cfiapfor 9(Commencing wifh _ _ . ._ , r ..� ' � � POWER AUTHORIZE� - �'- �-: - �� '- � '�-' ��- "�''� �' -"`�� -- ' ' Secfio.q:OOOj al Divisfo.�•3 of fhe euslness vnd Profas- � � 11Tl!ITY CO.NOTIFIED � , , . a�ons Codo)or tha�he 7s exemp�lherelrom and the basrs . � ' - . .-�or lho..cllegad cxemptlon. Arty vlolal;on o!Secllon . . . __.... _ .. .._ . _ . . . �. .. FINAI ' �c� --.• ..-•.-_�-„ �:,:'` :- .'-.� � . �:� . ..7C3f.5 by any applt:cnf ior a permlf 3vbjecfs fho oppli� . . _. -�itler on-yionf � � - �� conl to a eWil penclty oi nol more�hon iWo hundred . .. .. ; - �. i ._ ..:NOTES . .-.. . . . . . . . . .__.. ... �. �- ' .dolfars(S500J.: .. �. . . .. ....... . . � ' ' �.,. ' ' .. ..�1,os own�r af tha Properfy wi�l do thc work,and ' � � � �ihe s!ruUurp is nat,inter.dod or oNerod(or sale. � . � � � ' - � � � . � � . ____ „ , .__ _ � ..�,�(Sa:.7044,IIv.+7n3s;andPro/r,sslonsCode:- TheConfrac � � ��� '�" " -- - ' - .tar's Llcenae low does nol apply fo an owner of proparly . � �.. ' - � �� "" ` �� - �, , ' who 6✓i;ds or�lmproves :horeort, end who does such � � � ��� � �-�.���� " � ' � '-"' -�--��" � -- - � worY,hlmw(f provlded 1F.ef such-improvemenfs ore nof � � -- � - --- -- -----����----- -� '' ��- ' � — "��" �' � ��mtrnosdoro4urndforsofo.dl,-however,thebulldingor , � � ' � � � � -� ���� ��-� � '� ,imprcvamnnf b scld wilhln ono yocr ol romple�ion,fhc ,_ � � ', ` � � � � � ��� � '-'�ownor-bvflderwfflhwelhc6urdenofprov)ng�hoihedid � --- - ' ��`�- � �� � no�6ul'd or improva for thc purpose of safo.) - �-- � � �, _.:_. ---....1 � '� �� .�_"._':�_.. � '. ,...._ . . �,. _ . -. . . . -- _, - . ' � ---��I cm exempf uider Se�. ��. - '. --., - ... .. . ; _.___ . __ ..__ ...: .__:. ." _ ... ' : . '� - � -�- __ . _ ._ .... ,.,;.... � _ . . . _.__. . .. __.__ . . _'-.�. . , . "_ --�-..- , —' . .. --_. -- _ _.__ .. .. . . ._ �. ...B E P.C..fcr this rcason � ' • . . , .,. . . . . _. . , . � . .. . ._ . _ . .. . � .�._ r . _ � _. . . .,� � � .� -' �--- .._: _,_ , � . - . . ..�. . . ��, .. . - . . . ._Octe � -- � . . � � '. ' � ' , Owner_ � . .. . . ,.. . ,_ _.._..._. .._. .___ . , � . , . . _ � . .: ,. . . � . _ ... , ..,. ...... .... .. ..... . . . . . . __ . ..� - , � _�.;�. : - . . .