HomeMy WebLinkAbout1765A , _ .. .�� t�_:`- $_�,� . _
i' I � WORKE�COMPENSATION D6CLA 76A663 APPUCATION FOR ELECTRICAL PERMIT � {�
'V •(/ %f/ �j� �J�� �f-/CE-BO6G(2�80I
I hereby aftirm that 1 have e certif�wte at consent o x�t �� COUN7Y DF LOS ANGELES BUIIDING AND SAFETY !J
insure,or a certificate ol Workers'Compensation Insurance,or
� a1 c a�h/fiepd�cop�y/the e!�o�f f(Sec.380 Lab.C.) � � � T � �1'� �
�\ Po�cyNo. r��" (:ompany FOR•APPLICANTTOEACH'NNO, FEE DORESS fp7 / Ia �I} C�� �
� . , New Rnidentiel Bldgs.&Poois
� Certified copy is hereby fumished. � 1&2•Family,Sq.Ft. S — 5 LOCALITY �,yE}L N u�T C��
Multi-family Sq,Ft. A
� � Certifed coyy is tiled with the county bui�ding Inspection qe31dentiel Swimming Poois CHOSS ST -
departmenL . OWNE R OR
Date Applicant Outlets:R��' �Sw.�� �A M NAME s�t2A �`'�
�enc �oSS�QRkA C,VK it�D.
� � �c FirSt 20 � '� ' ADOHESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.J�.� Additional � �-o
CI7Y y/ �,,,N(/'r" T�I No.,' /$�• � T
COMPENSATION INSURANCE �
� PLAN CHECK a-
APPLICANT O
(This section nead not be completed if the work involved Li hting Fixmres First 20 ��' � � V
� by.the permit is for one hundred dollsra (5100)or less.) 9 D Addfiional AD�RE55 ��
7ota1 No..�_ p
1 certify that in ihe performance oT the work fot which thts Fixed Appliances Not Over 1 HP cI7Y T�I No. . f.,
� permit is[ssued,I shall not employ any person in any manner PERMIT V
, So as to become subject lo the Workers'Compensation Laws. Range_Heater,�.W. � qpp�ICANT P�PER ��G7! I L�, � a
Oven _Drye�._W.M._ 3 p�, ! ,3 nooRess Il'JE�O ON ptl z
1 Date Applicaot 7op _FAU _W.H...�
� Hood—Fan �Other_ � G-�^�-S b
� NOTICE TO.APPWCANT:If,afier making this Cectificate of Disp, _Room Air Cond._ �'� �' UC N E OR O el No. O
�aemption,.you should become subject to the Workers' REG.NUMBER 3rr /�C1ns a
j Compensation provisions of�the Labor Code,you must forth• power Apperotus&Large Appliances DISTRICT NO. P CES ED BV
. with comply with such provisions or this permit sheli be �
, deemed revakeJ. Size&Type HP,KW,KVA,or KVA � ���
' Upt01 InCI, FINAL �
� Over 1 to 10lncl, DATE VALIOATION
UCENSEU CONTRACTORS DECLARATION Over 10 ro 50 Incl.
' I here6y aftirm that I am licensed under provisions of Chapter . Over 50 to 100 Ina PINAL , .
'� 9 (commencing with SecNon 7000)of Division 3 of the Busi- Over 100 BY� �
� ness and Rofessiona.Code,and my license is in tull force and �
. effect. - ' $ervices �
1 License Numb Lia Clasa�-1� �'200 Amp.Under 600 V . � '�7 E�� �
� I. 201•7000 AmP.Under 600 V: t�':� ��..
.� Contrac[or--i��� Date�- Y� Over 1000 Amp.or Over 600'V � . . �f,� � ����? .
� i
HOME OWNER-BUILDER DECLAR TI N Temp.Power Pole$Appurtenances . ,Q Q 3 f-F��
i hereby affirm that I am exempt Bom the ConUacmr's Sign with One Branch Circuit ,
License Law for the iollowing reaxon (Section 70�1.5,Busi- Additianal Sign Bfench Cifcuits .
� ness and Nrotessions Code)c . ' � � �
�� Misc.Conduits ffi Conductoro _ �
� I,as owner ot the property,will do the work and[he ��her 1See Complete Fee$eh¢dule�— �
. s[ructure is not intended or offered for sele (Section
� 7044,Business and Rofessions Code). ,
� � CONSTRUCTION LENDING AOENCY . � .
� I hereby effirm lhat lhere is a construction lending agency � . � �
for Ihe perfotmance of Ihe work for which this permit is pERM1T FEE (Sub-Total) �
issued(Sec.3090,Civ.CJ. � -
Lender's Name PLAN CHECKING FEE (One•Fourth Pe�mit Fee) �
Lender's Address PERMIT ISSUING FEE ' � � � �
I certify thet I have read this application and a[a[e iLat the TOTAL FEE �2� � � �
above informsti is rect.I agree to comply with all County . . .. � �
ordinance and St e ws regulatina Electrical wiring, and . ' �
hereby ( riz r res ntatives of this Caunty[o enter upon .
, the ab e- nt' ne rty for inspection purposes. SEE'REVERSE FOR EKPLANATORY LANGIfAGE
J .
4,
Signatur o n i e ate - .
_
- � ..
_ . . .
, � . ' O�VNGR-BUILDER llECLAR.ATION �
- � C i�� _ I hcrcby a;frm Iha[1 am cxcmpt fmm[hc Contractor'S
-� � _.AP ,POVl�LS ' '�� DATE �NSPECTOF'S ,. . LiCI•n5e Latt' (Or tlte (Ulloti�'inF�TeaSon($eCfiOn 70,71.5.
. ,i - sictvnTune � " . . .. . . , 'fi�isinerr mid ProJessions�CodeJ: Aiiy city� or comity.
��� -� � - � �7ENtA.POWEff POLE - ---� - - � v.'hldi rcquires a�pennit fo mrrrfn+ct, after, improre,
. .i . . . . ,, . .-..� . .. . , ,
� - � �- � - � -" U�dOeRSLae woRY � - � � - - ' ' . drrnolislr,or reparr mt��srrtreture,'�psiar to irs issucrrcc,
- . � �. . � , nlso.rcquires the applica�u jor rucir pennit ro file�a
- --- ROUCH CptdoUi7-: -- -- - � - � � ' � srgi�ed smtement dm� he is ficen.ced pursuant to tlic
��� - � � .,',��,^���, --(`._: � . , , . , . �prorisiau oj N+e Conlractor's l,treirse l.air(CLnpter 9
- � - wiRirvG �- •y� . C��� ;�r /eorftmencing.whb Sectiort 7000J of Diririwr 3 oj dre
� ,_.; �: � ' ' _ .. ,� . .
i . i. .�=--. . 6 'rc
. .f1Y.TVFl ., •�.... :.'. . ; , . �esu s.c mu/f7ofessinnr CodeJ or drat he is cxemp�
+ � _ -`�� .. tlrerejrom m:d!he basii jor!he allegcd exeniprian.Any
_ . , � � � ..' _' po��t�i�;�aUiApttiz[o � -� -�-�� • � � croln7ion of Section 7031.5 byanj'epp(icmifJoraperntif
i IfTILITY CO,NOTIFIED-_ - S.16JCCfs f)IP QfJn(fCallt 70 0 Cil'l�/�PIIO1ty Of Ii0(mOrC ilfal!
•— - - ;� : , ; u d�ddou
. � ., . . . fi�'e h n r ars/SSOOJJ ,
, . .-._ . . . -� FINA�. " -�'�:.trli.�.'r,+i'"�!teic� -.. � • � . ���.: - � - ❑I,as ou�ner of thc property��vilt Jo the���ork,and
�, . ,- . . � � - � � "i � '��� ' ' , ihc strnctnm is not intcndcJ or offcrcd for sale.
_ � � � r�o7Es � � � i . � � � � � � � � /Sec. 70�t3,Rutin.ers m�r/Profersinns Code: Tltc Co�r•
. �! `; . . �-:=:"s'.'', . " � � � . �t�acmr i /rceirsr,Law does no7 app/y �o-an owi�er of
. properf��wlm buildr or iinprorer thrreon,mrd who does
� u�,%.:. . . +.�t't�\ ' ' � � '',i, . � ,. � .. . auch work himsclf provided Nrat s:�d� i+nprovements
� << , , are not intended or ojfe�ed for sele. !j, howeves, ti+e
, -— - � - -� - � '� .. ,;.� . Guildin; or 6nprorement,is so7d �vi�kin arre }�ecr oj �
'� ' •,:-� �' ' - •- .
, ._, ._ . � ;-!--t .., . . rorxpletiar, Nt_^ o�vner•b+�ildcr �cii! harc-rhe Levde�t ��
_ �: _ _ . . , . .
` ' . . � �� ` �" � � � ' .. � of prorir+g diat he did �rot build,ur impro�•c far,d:e I
. ptapose of sn/e.J �
� � . . . . . . . .
� I am exempt under Sec. .
__ - _ B&P.C.for tl�is reason
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: . : ... . I_ Date
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