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HomeMy WebLinkAbout1704A � � WORKERS'CO�iPENSATIONDECLARATION 76A663 APPUCATION FOR ELECTRICAL PERMIT � CE�808G(2-80) . 1 pereby a(£rm that I have a certificate ot consent to self COUNTY OF LOS ANGELES BUIIDING AND SAFETY - insure,or a certifica[e ot Workers'Compensation Insurance,or � � c / � 7 - . n certifl d p hereot(Se/yc.3 00 a/b.�C.) �� V� J� 1 � `� � Nnlicy D�9Pe�Y_Lmdl"LS�L��:1dJlL.y/ FOR APPLICANT TO EACHIN NO. PEE ODRESS D R G �A J New Residential Bldgs.&Pools � Certified copy is hereby furnished. � 1&2•Family,Sq.Ft. $ — E LOCAWTY Multi-tamily Sq.Ft. — N A �Certified copy ix fiied with the county buii n inspecdon CROSS ST � Residential Swimming Poals S �� , depart ent. . OWNER OR . �p FIRM NAME Date � � Applicant � Outlets:R��ight�L Sw.xO � MAIL / Q� Firtt 20 ADOHE a � � CERTIFICATE OP EXEMPTION TROM W RKERS' Tatai No._Ll— Addi[ional CITY Tel No. } . CO�iPENSATtON INSURANCE � PLAN CNECK �- � � APPLICANT � (This section need not be compieted if the work invalved - �Q f V by the permit is for orre hundred dollars($100) o� �ess.) Lighting Fixtures First 20 ADORESS � Additional I certify that in the performance of the work for which this F zed Appliances Not Over 1 HP CITY Tel No. � . permit is issued,I shall not'employ any person in arty manner . PERMIT w so as to become subject to the Wbrkers'Compensa[ion L�wa. Range�Heater.�D.W._ ' APPLICANT y _ . Oven _Oryer_W.M._ AODRESS O � ��U z . Date Applitant Top _FAU W.H.T ^ � Hood_Fan �Other_ f CirY �� �i N 1 _ � N071CB TO APPWCANT:If,after making this CcrUficate of Disp. _Room Air Cond� �'�D � 10 410ENS OR Exemption, you shoWd become subj¢ct to the Worker5' REG.NUMBER Claaa . Compensafion provisions of the Labor Code,you must forth• power Apparetus&Large App�iances � �15TRICT NO. PROCESSED BV with comply with such provisions or this permit ahall be Size&Type HP,KW,KVA,or KVA deemed revoked. � � ��2-� � Up to 1 Incl. FINAL Over t to 10 Inci. oATE /� �j VALIDATION � UCENSED CONTRACTORS DECLARATfON � pver 10 to 50 IncL ^`o� • I hereby affirm that I nm Iicensed under provisions of Chaptcr Over 50 to 100 Inc. FINAL 9 (commencing�vith Section 7000)of Division 3 of Ihe 8usi- Over 100 BY ness and Professions.Code,and my license is in tull torce and e(fect. . � $ervices . � " 0-200 Amp.Under 600 V ��� � `30 � ' ' License Nu�Lic.Class�� ��� 7��i{�i !JI 207•1000 Amp.Unde�600 V Contractor �ate ��b I Over 1000 Amp.or Ovef 600 V ?� • •n • •� Itsl �1�5� HONE OWNER-BUILDER DECLANATION Temp.Power Pole&Appurtenances � . Sign with One Branch Circuit� '�" � �'��l�� , I hcreby affirm that 1 am exemOt from the ContractoPs z e.R � ' ', License Law for the following reason (Section 9031.5, Busi- Additional Sign Braneh Cireuits .. ��:2� ..-� , ness and Professions Code): � � � Misa Canduits&Conducmrs '� ' � I, es owner of the property,will do the work und the Other(See Comp�ete Fee Scheduiel— ' stmcture is not intended or offered tor sale (Section . 1044,Business and Professions Code). � CONS'CRUCTION LINDING AUENCY , I hereby nffirm that there is n constructian lending ugency � � ' for the performance of the work for which this permit is PEFiMIT FEE ISub-Total) � � � IS5112d�SCC.3097.C1V.C.�. Lender's Name -- PLAN CHECKING FEE (One•Fourth Permit Pee) � � LendePs Address PERMIT ISSUING FEE p - � I certify that t have read this applicatlon and state that th� TOTAL FEE G , above informaHon is correct.1 agree to comply wlth ali County ordinances and State laes regulating Elec�rical wicing, and ,- hereby authorize representatives of this County to enter upun - , the nbove-mentioned property for Inspectlon purposes. �� SEE'REVERSE FOR EXPLANA70RY LANGUqCE ��� ��16L � �5 �� . . . ' . Signa[ure of Permitte • Date � -� ,� ' ' o���.rr-ru�t�r:a nrc�AR:lTION t�. � � ':i.; j:`!LL}�� . . . . i herchy�afti:m tluc 1 em c�rmpt fcom fhc Contr:�ctor's � � � irvsrt-cTo�t's 'I,i��i-. T.p' fur,thc fullu�m,�[c�coc GSectiou i031.5. � .Af'f'FiO,l'ALS DATe �IGf.i�Tt1FlE j � � :� . . ' l9l,.n,sc m,d frofcsPiuit C,ndr/'�.Irry citv ur�romrm ' . . . . .- � �,- �� "[LMR. o'h'[fi POLF . . • . x'Aic1: requlrCs a pi'nnlf rU co!t:tnlcr. clter, int(�rocc. . � i'��1�.,- - � � - - - - � - � � dcrrrolish.or repair r.ny stnrct::rc,p�ior to itt rssumttr. �UyDEh5LA6VPOFiY. g � cl<a reqmrre !Ge appLcen! fur sudi pern¢7 fo fil�:a � F'OU�.H.CONOUtT . `� ] �- . s7�r_c f srat�r.�rt 11�7 h<� r. 1�.�'ru�d J�rr-�nnt to t7ic . @ —'��—�----� � �����L ' Pro�r.u�s o(N Contrac7a 5 I.iccnsc lai� (C7�aPtcr 9 � ' ' '� LVIRIMG � - - (ccrr:r>>cmg ��r{Jr $'ctinn i0f0/ of Ut4lria!i_3 of die ti: . , i'i.2�tUHeS��,�4� "' �� " � ` � . _` Ihnmcc.c mi�l�Sofccc�nrev Cede/ or rf�er Ac is eaetr!pt . _ . • � . - .- _ —; . , . � ���:� . ll,ercfrom nnd tlte f�2;�s'fUr�thr o!(ege��esenq�fion..-Inv . . . ' � .... POL"!E�nU�T4lvaiZCo � � - rrola:io�r uf Sect�n�� 103L5 f>,t art}'q�>pliccrrlfora permir UTILI7Y CO.NOTFI=O � .r[t6jects tl�e apj�l:ca�rt In¢cit'il Jle+ta(!y of rm1 n:ofe(llan .. . - �� . /� � `.'� . fA�el:::r::!�cddo!'r.•s(SSOOJ.: � .� � � . __ FINAL �r.tCd. �G�t�"f2PSL� . ' . ❑1,ati a',-:ncr of tlit propert}'a�ilt do Ih�icorA,and . . - - ' �hc stru_tncc is cot ii�.tcndcd nc offcrcS tor sala. ., NOTES � � .. . . S c i0-F�1, R:c[iners nud Pro rsioru Code: Thr Cal� . . . . '. '•_.j'• � � ' . �,��:. f�. �. � trr.rtur's Liccr.rr Lc��� doer imt�nPPlt� ro an n�cr+c.�of . ' r . .'1 � , . � p�aperr� �il.o Lu.ld�ur imp�ores rher��orr.und��l.o duea� � _ . . A'� . - . . . � . sirch sarA hin:sclf proudcd thr.7 surh i�r�proicntcrtLe .. . - nra r,of intriide<;nr oJfa'rcd�for�mlc. !f. d�reerer. flre . ... ' . _ , ' . .. • � _ - . � ' buikGr:,� or i�nprorcrrcut ir sold �ritliir. mrc Secr oj .. :.cnn:p,�iioii. 7he�o�r�ier-huil�ler }rill hel'e tite.Gi:rdeii .. . -. . . . . . . .. .. . . � ., . . ,. oj.prori;r� th;7r he di;l no: build or iinprorr fnr ti:c � .. parpo�^of sR(c.l � .. . . � � I am esempt undcr Scc. . _ $R P.C.for thi;rzason � � .. �- • D:rtc . ' � p.,cqcr , - r . � . .. . _ . . _ ...._ . � . \,\ , _ ' .. �- • --' .'.-..'.`.-• , .. - .