HomeMy WebLinkAbout0784A T WORKERS'OM ENSATtON�EC�ARATI� 76A663
� �E.aoe�«.80, APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm ihat I heve a certificete of consent to selt COUNTY OF LOS ANGELES UILDINCi A $AFETY �
insure,or a certificate of Workers' ompensation Insurance,or � � i
a certif cf�y thereof("$r�c.3800 Lab.C.) +. � " �
��Yl1�IY.P1GYc{� � �✓s FOR APPLICANT TO FILL W . . JOB
II po���y�Yo.U" N�U�oCbmpen EACH NO. FEE ADDRE35
�f New Residential Bldgs.&Pools
' � Certified copY is hereby furnished. 1&2-Pamiiy,Sq.Ft. S — S LOCALITY U
Multi•family Sq.Ft. �
' �Certificd copy is filed with the county buildinQ inspection CROSS 8T
Rdidential Swimmin9 Pools
deparlment. OWNER OH ' )
� i/ � ''/ f FIfiM NAME /
, Date�APV�icant � Dutlets:Rec�Light�Sw. `� .� MAIL �� `/
. �_ / Fvst 20 ADORE55 ) �7 � � c��/ ,
CERTiPICATE OF EXEMPTION FROM WORKERS' Total No._,1� Addrtional dTV � Tal No.�� l.,�
COMPENSATION INSURANCE . - PLAN CHEC � d
(This seCtiOn need not be COmple�ed if the WO[k InvoWed D ' j�APPLICANT � U
by the permit is Por one hundred d011us (SI00)or 1e�s,) Lighting Fiztures First 20 A�ORESS
Total No.� Additional �
1 certify that in the performance oC the work for which this Fixed Appliances Not Over 1 HP dTV � � 7al No. �
� permit is issued.1 shdl not employ any pereon in any manner PERMIT ) W
w as to become su6ject to the Workars'Compensation Lxws. Range_Heater_D.W._ qPP ICANT� / '� a
� O�en _Oryer_W.M._ . ADDRES �!-� p Z
Date Applicant Top ,_PAU _W.H._ —
Hood_Fan LOther_ pp f CITY m��Tel No�3 —7.J', O
NOTICE TO APPLICANT:If,atter makinQ this Certiflcate of Oisp. _Room Air Cond� �� I � uCE SE OR l�
Hzemplion, you shoutd becnme subjea to the Workers' REG.NUMBER� � Cl�n
Compensation provisions of the Labor Code,you must forth- power Apperatus&Large Applienees . DIS7RICT NO. � PRO SED BV
with comply with such provisions or this permit shall be '
deemed revoked. Size&TVpe HP,KW,KVA,or KVA
Up to 1 IocL �
. - � �_ Over 7 to 101nci. — FINAL .
�LICENSED CONTRAC'fORS DECLARATION DA7E G / VALIDATION
. Ove�70 to 50 Ind. �� �O
Lhereby affirm that!am licensed under provisions of Chepter Over 50 to 100 Inc. � FINAL � �
� 9(commendng with Section 7000)of Division 3 0[the Busi- Over 100 � BY
. ness and ProCesaions Code,and my license is in full force and = C �£�r ��'
� effect, .'{ Servic¢s � ' 'o e e'e�
License Num ✓//��'' Lic.Class ��� 0-200 Amp.Under 600 V � ,�,�� ���:,�� ,
� / , . ��/ �/ 201-1000 Amp.Under 600 V _
Contractor � � Dare. E Over 1000 Amp.or Over 600 V �, °���� �� _ �
� HOME OR'NER-BWLDER DECLARATION Temp.Power Pote&Appurtenences �f ��—� �
[ hereby affirm [hat I nm exempt lrom the Contrector's S�gn with One Branch Circuit � . ,
License Law tor the followinQ reason (Section 7031.5.Busi- Additional Sign Branch Circuits . .
ness and Rofessions Code): �. _ - .
Miu.Conduits&Conductors ' �
� I, as owner of the property,will do the work and the Other(See Complete Fee Schedulel— . �
structure is not intended or offered for sale (Section � �
. 7040,Business and Professions Code). .
� CONSTNUCTION LENDING AOENCY
I hereby affirm thut there is a construction lending agency � �
for the Derformance of the work for which this permit is pERMIT FEE (Sub•Totall 33
issued(Sec.3097,Civ.CJ. - � . _ �
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Feel
LendePs Address . PERMIT ISSUING FEE � . j} 0
I cerUfy that I have read this applitation and state that[he TOTAL FEE � �Z �
, above informetion{s correct.1 agree to compiy with all County . � � .
ordinances and State laws reguledng Electrical wiring, and ,
hereby aulhorize representatives of[his County to enter upon
the abovo-menNoned property for inspection purposes. � .. SEE'REVERSE POR EXPLANATORY LANGUAGE � -
� �c��� � � � �
, SignatureafPermittee Uete �
. � .> ��.. ,: • ! '"t ... . . .� � .: . .. ' . , . . . �' . . . . , . ,
,_ „ ,. .
_ OWh�R-13UILDGR DECLARATION
� � � ' ,�.� � � - � , � 1 hcreby affirm�Iha[I nm cxempt from tLc Con[ractoi s
, _ _.__...,.__.._.. ..� � ._ . . .. _.. . .
'APPFlOVALS � DATE ir�SvecroFz�s . , - � �� , .Licrnse Lan� fqr ttre follo�sing reason/Sectiore 1031.5.
, -_ - SiGNtiTuaE- � - � . Rdisiness'arid R'nfcrsions Codef.�Any city o�mumy
'� _. .._. . _. _:_ .., .. . ..
, 7en�F.eo��.��ri POLC �� �--� �-- - � " � � ' ���lrid� requires a pernrir ro ca�srnict, aher, lmprovc,
- �� --- . - �' ONDERSLAE l"JORf; � . -� � ��" ��� � � demolrclr, or repQir mr}•sfrt7cture,prior to its issumue, �
� - . - �� a7��o rerruirer the applicant for tucH pernrit to,fi1e.a
' -- -�� � -- � � aOUeticotvoUiT - � � ----- -� � �. - - si;neJ stare�r�e�rr �irat l�e�is licerued prrrs�eanr�to tlre
, . ' - - �^�tftiFic'- -, ��- ' � prorisiores nf drP Cartractor's License Law(CNaprer 9
. • � . .._ (roirvrrcnring �.,�i�h Scrtion J000J oj Dirisron 3 oj iiie
. . - , . � _. . FIXZURES .. ". � ���' � - .-- -� .- - - �, _ � Buarr�ess wtd f'rojessions Code/ or drat hc is rzenrpl
. . ..._- I _ .. _ _ . . ,. , . � 7lierefror��m�A die'basis for the allegcd ezciirplion.Arrti� �
_ ._.- . -__ .POwen.Au7�foRizEo . � vialatinr�nf Section 7031.5 bya�tyapplicaret forQ pennil
'" UTi�IrY c0.n'OTiFieo- - . ' ' miL%erts Nic opplicant to a ciril r�ena'ty of r.ot rnore than
�.:•:�, . . . . d do1!^
' �'-� '-' ._... .-.. . .., .; . firch:u�dre ..rs(SSOOP.:
' . . __._ Fi��a�-_-.._ �sxlr.t Wt �4wt� ❑1.as ou'ncr of tLc roperty will do the u�ork,and
-- � - -� �' � ' .the structurc is not intended or offercd for s�le..
. .. - . -. - Nares ...__ .� � . � . , ' - . .� .. . . . . � �-(Sec. 7041,�13u.rines.r mid Profcisior,s Code: Tlre Con-
� � �� � - � . .�. ' . � . . . �trector's l.icensr Law�does not apply to pn owner of
� . . . , , , , . . propert}� rchu Guilds or irnprovec Ifiereorr,mrd xd�o does
� � � � � - �� . ' � � � � . � s��c/r x�ork himrelf yrorided that such impro�•enrentr
. � . � , . � . . � , , are not-0rtended or offered�for'sale.-Ij, howerer.�1lte
. � ..� . ; � . .� �� .. � . . �. .. . .. � .... 6urlding or improrcrncrrt r� mld wilf�i�t one ��car of
- �ro�n��letion, fhe orvrterbuilder wi!! imre the b�trde�r
..... . _ ._ _..... . . . . � .
� - , , . ,oJ provi�te�tltar ire did rwt build or iirlprore.jor the
, . � � . ..- .. � ,. . . P'.�rpoaeojsafc.J � . �
]am excmpt undcr Scc. .. .
� . .- -- ll R P.C.for this rcason `
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, .Date
- , O�ciier
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