Loading...
HomeMy WebLinkAbout1290A WORKERS'COMPEN:ATIONDECLARATION �aA� ,o.B, qpp��CAT10N FOR ELECTRICAL PERMIT I here6y affirm Ihat I have a certifimie of consent lo sel4 CE-&MC � i�su�e,o�a ce.rfimte of Wo�ke�s'Compe�wGon losu�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy rhereof(Sec.3800,lab.C.) a cy No. Company FOR MPII[ANT TO FILL IN J08 pP , hfied topy is hereby fumished. New Residentiol Bldgs.8 Pools EnCM NO. fEE ADDRESS 6��'�SV(� �' CeniTied copy is filed with the toumy bullding inspao 1 8 2-Family,Sq.FL a = 5 LOCAIITY�.�,�(/(l T' NEAREST J � tiondepartment. /���� Multi�fomilySq.Ft. CROSSST.(� �ll/(��d� Dale �`Y �� Applitont� G(f� Residemlol Swimming Pools . _ ' OwNER oR ♦� �7 ilRµNAME .,� S/'�� . GERTIFICATE OP EXEMPTION FRO WO fR5' Outlers:Re��LlghtLSwJse. ��� " ��Z� ��(/ `.rN �j, � COMPENSATION INSURANCE �'�y F.5'� — AODRE55 ' (Thls s�Nion nMd nof b�complN�d{f th�work involv�d by To�al No.=1_ CITY � Tel.N .r�SY�y- , �M p�rmif Is for on�hundnd dollan(5100)or I��s.) Addilianal .�"�'UG% � I certify that in the performance of the work for whith Ihis pppN�MK . permii is issued,I shall not employ any person in o�y manner 7� �� — so as to become subject to the W kers'Compensy[ion laws. Lighting Fiatures First 29 ADDRESS � �/-r�i7� ,CG��' a;cf- Additional '. ,�,,,__���!f / ��p���� Total No. QTY Tel.No. DateJ�d�1\pplicont�r�' c�� Fixed Appliances Nol Over 1 HP PERMiT NOTICE TO APPLICANT: 1(, afler making this Ce�lificale of � ApvIICANT�f{� � � Exemption, you should become subjeU to t6e Workers' Range_Heater_D.W._ . ' Compenwtion provisions of ihe lobor Code,yoL must forlh- Oven _Dryer _W.M._ ADDRESS�.S�r��Cf� �i1}'N D���. with comply wifh s�ch provisions or ihis permit shall be Top _FAU _W.H.— deemed tevoked. Hood _Fon _Other_ . CITY�� v�r (�(� Tal.No.sy��3 IICENSED CONTRACTORS DEGLARATION uceNSE Oa Disp. _Room Air Cond. — REG.NUMBER a Class. I.hereby offirm thal I am licensed under provisions of Chopler 9 3 �� � (commencin with$ection 7000 of Division 3 of the Business } 9 � Power Apparolus 8 lorge Applionces DISTRICT NO.. ED BY a ond Professions Code,nnd my license is in full force and eHecL � � f D Size 8 Type HP,KW,KVA,or KVAR Ucense Num6er ��'�s!� L(c.Clasz C�� Up to 1 Incl. F�NAL � 0..' �K^�7�G�ZY D I r � Over 1�0 10 Incl. � DATE ;� 2�..�f OO CoMroUor Oafe YALIDATION ❑ Over 10 to 50 Incl. C� FINAL I om exempt,under Sec. Over 5010 100 Inc. 8Y pW„' � B.BP.C.for ihis reason Over 100 N Z Date: - Servic�Swbd.,MCC&Ponelboards � , � ',.L Cl-�(10 Amp.Undar 600 V 5 �o �129.0A Signature 201•1000 Amp,Under 6A0 V /O fJ. Fa Yn� ❑ Over 1000 Amp.or Over 600 V . �• • • . •`Z � Exemplion for Reg.MainL Elect. I • •E�5 O SINGLE FAMILY Temp.Power Pole 8 Appurfenances HOME OWNER-BUILDER DECLARATION Sign wilh One Branth Cirwit � •E&5 Q� I hereby affirm thm I am exempt from Ihe Cootroclor's license Addifional Sign Branch Circuils • • Low for the following reason(Sedion 7031.5, Business and - I Q,� b—S�I Professions Code): � ❑. I,as owner oi the properly,will do the work ond Ihe Misc.Conduits 8 Conduclars . sirucf�re is no1 in�ended or offerad for sale(Seclion Oiher(See Complete Fae ScheduleJ_ , 70d4,Business and Professions Code). � CONSTRUCTION LENDING AGENCY - � I hereby offrm ihm�here is a construction lending agenty for OU the performonce of ihe work for which this permit is issued PERMIT FEE - (Sub•Totol) � _i. „ . �Sec.3097,Civ.C.). � � � /� /�� PLAN CHECKWG FEE - Lender's Name � 6� ( � � � PERMIT ISSVING FEE Q � Lender's Addreu '� � I tertiiy fho�I have read this application ond siate that the TOTAL FEE � � e6ove informa�ion is correct.I agree lo comply wirh all Counry ordinonces and Stole laws regola�ing Elecfrical wiring,ond . . hereby av�horire representptives of Ihis Counly to enfer opon � � ihe above-meniioned property for inspec��on pvrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � - ��'�/�� O_ �8 Signoture of Permittee D te � � _ _ _ ._ .- - ---- _ ___ _ � __ � . , - � � � � � � , . 7. - .._.. .__ ._._.. . . .. —. .. . -. .. ... ... . ...- - - O'�^lNER-BUI!DER 0°GLARATION � - AF7ROVA[S .DATE _. o-c � .c . , � � .. .. . . _ .. . . � " - - � SIGNATURF ��. . - . �... -.. _ . - �� ' � - � TE:1F�.�F04VER PO:f �.. - . .. -� . . . ���.�. . , 1 herohy pffirm�ihal I am�rxemp�from Ihc Con�ratro%s � � _,_ _ . ._ _ . .. .. � .�� -� � LicAnse�taw for cha followinfl..eo:on (Secrion 7037.3, ��- - - � � UN�ERS.ASV:ORK � . _ _ � _, . � , 6usfnessarto'ProfessionsCode)•Anycltyvrcounrywhkh - � RO'JGN CONDUtT � � ��y�7 � � �-�- � � � �requlres a pormfl fo consfrucf,olfca lmprovc,domolish.� . . ... ...._.. _ .. .. . � � ��_"-�-C --� � - - --ofrepclr.ony„e�ruNore, ptior�o Ifs Issuance, olso�re- � � -- �--�- -- -� ��-� � 1"JIRING_� �� - " �.�� , , ;�,:,- ` -'qufresfhnepp!1conHor.suchperrnitloftleesignedsta�e- � . �� - �� �� - FIXi VRES'�-'- � - ` , . �" mtnt 1Fe/6e Is krensedpursuanf 10 tho provislon:01 fhe � - . , . ' . . . � Cont:oclor}UCenso Law(Chapter 9(commonUn3 wifh - . . . _ FOV:ER AU7HOn^2ED��� � � � - � � -�� ' � �� � Sedron 7000)of Divqlon 3 of the Business and Profes� - � � � - � stans CodoJ or fhaf ho Is exempt therc/rom and the 6asis UTILITY CO.NOTIFlED � . �- . � for lh^ c!le�ed ozemption.�Any vlolct7on o!Section � �� FINAL _ `fifc�o _Yronl � ' `. "� ' 7GJI.5 6y ony appliconi for e permlf subfects fhe appl!- - rt ''"� � -canf fo a�clvll penelty of nof mo�e IhenJive ho�d�ed � . . . . �" �.. . NOTES . . . � - � � � doflars(Si00)..�. � . ; � _� ' ' . -� .. _. __. ._ . . _ . . .. . , ... .� . . , . . . � ❑I.ns owne�r o(tha proparry will do ihe werk,and � " � ' , thv strudura ls not IMonded or offe�ed for sole. � . � � . . � ,._ ,. � . , - (S3c.704d,Businoss ondFro�ossions Codo� 76e Contrac � - � - � � fo%s G:anso Law�!ees nol cppfy fo on pwner oi propeny . . ' . . � � ' - . , � . � , ., , who 6ul(ds or�Improvos lhereon, and who c+oos such �� '-- - - �- �-�� � --�" ��- � � � - �� �� - work hlmielf provlded�fha�such lmprovemen�s ore nol • �� -�' �• - ' � " ���� '" � - � . � - �-- - - ' - ' �- � � �In�undedorc/forndforsolc.11,howvveq fhe6utldingor . .._. . . .. _. . . � .. .. . .. .. . . . ' � - Improvemenf Is sa!d wilhin orie yeor o/complefion,.tho � , � -. � � �ownnr6u((d^r v�ll1 hove fhe 6vrdon ol prov(ng fha!he did •. - "' - � � � ;mt 6u!(d or Improve!or iha purpose of sa1c.) � - � � — � 1-om exompt und�r,5ec. , .... . . � . . . - - � � .__.B 8 P.C.for.this roason . ` -- � � _�:. ,.� . . ... '_ . . - . . . ..Date - �-- . . � � � Owner ' .. � � �