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HomeMy WebLinkAbout0972A � WORKERS'COMPENSATIONDECLARATION 76A663 +o�e� APPLICATION FOR ELECTRICAL PERMIT � I hereby affirm that I have a certificale of consent to self Insure, ce•aosG � or a cerfificate ot�'/orkers'Compensatbn Insurance,or a certif�ed COUNTY OF LO5 AN(9ELES BUILDING AND SAFETY eopy thereo�15e�.���p��a�.C.) STATE FUND 500 Policy No.� Company FOR nvPI.�CANT 70 flLL IN . JOB � � � ❑ Certifietl eopy is hereby furnished. . � EACN NO. FEE� �RESS 24284 DRECKENRI G . New Residential Bldgs.&Pools LOCALITY DIAMOND SAR TR 42571 � .� Certified copy is filed with �he county butldirg inspectbn 1 8 2•Family,Sq.FL 3�91 $ _ $ art nt. � . . -� Muki-family Sq.Ft. rvEAFE57 . Fesidential Swimming Pools CROBs S7. '- . �oate Appiica�t' F��, n Fi�.FrTRTC Tj1C F�M��M.J.B ROCK & SOhS� TNC. CERTIFICATE OF EXEMPTION FROM WOFtKERS' Outlets:Rec,L'ght_Sw.— � ! ��- ' ^?,� � � COMPENSATION INSURANCE � � First 20 � ��E55 P.O. �BOX 3S8 '.,(Thia secib�nead rwt be completed N the work IrwoHed by the Tot�l No. qdditional CITY : _ Tcl.No. �-�ermit ia tw ona hunA�W tldlara(S700)w leas.) — -I Cer�i(y that in Iho pCrfOrmancE Of the work tor Which fhis pefmit . . P�aNCtiECN is ieeued,I shall not employ any person in any manner so as to AP���M become subjea to the 4Vorkers'Compensation Laxs.. Llghting Fixtures First 20 AODRESS � �' ' � Tofal No. Additional , CITY Tei.Na. �e A�P������ Fixed Appliances Not Over 1 HP pEqrmT rice ro APPLICANT: �I, attar making �n�s Certificate of n�aicnrrr E & D ELECTR Exemption,you should become subjec[to the Workers'Compensatbn Range_Flealer_D.W. , provisians ot the La6or Code,you must for�hwilh comply with such Oven_Dryer_ W.M._ ADORESS 319 MC ARTHUR WAY ��1 �provisions or this permit shail be decmed revoked. . Top _FAU _ W.H._, � C�TY UpLANA re�.n�o.946– � LICENSED CONTRACTORS DECLARATION Hood_Fan � Other, I here6y affirm lhat I am licensed under provisions ot Chapter 9 LICENSEOR (commencing with Section 7000)oi Division 3 0l the Business and - Disp. —Room Air Cond. _ REG.NUMeER 422589 Ciass�-1� . RoieSsions Code,and rtry license is in full fOrce'and eifect. DISTii1CT NO. AROCESSED BY Power Appafalu5&Large Appliances . /'1 �M . Size 8 Typc HP,KW,KVA,or KVAR '�/ 1 , 1 a1 an O License Number 422589 Lic.Cm�s,-s7 C—lO Up[o t IncL FINAI �� � E � D ELEC �[���[,j. Over 7 to t 0 1ncL. DATE ����� o vnuonnoN ntractor � Date�__�=i Over 70 to 501nc1. FW l �"� .❑ I am exempt untler Sec, Over 50 to 7001nc. gy U B&P.C.for this mason Over 700 � � - - � Dale: � �ry�ces,Swbd.,MCC 8 Panelboartls � � - � - � � � -Z ' 0-200 Amp.lJndcr 600 V � Signature - � -�201-1000 Amp.Under 600 V - ' - � �� ' � - ❑� � � � - - - - Over 7000 Amp.or Over 600 V � Exemption for Reg.Maint E�ct. � ��9 7 2 R- ��„/'�� � SINGLE FAMILY �� Temp.Power Pole d Appurtenances . _ _ HOME OWNER-BUILOER DECLARATION �S�� • • � •�L ' I��reby aflirm ihat I am exempt from tho Contractor's License Law Sign with One Branch Circuit for the following reason(Section 7031.5,Business nnd Professions � -��bnal Sigo Branch Circuits - . � •� (J.Z� (1 coacJ: • 9 1 4 2.1 C� ❑ I,as wmer of the pmperty,wiil do the work antl the slructuro �sa Contluits 8 Condudors � '� � � - " is no[intentled or olferetl for sale(Section 7044,Business Other�See Complete Fee Sc�edulo)_ �8'?ll�8 7 and Professions Cadc�. , CONSTRUCTION LENDING AGENCY - . � � - � - I hereby aftirm ihat them is a canstruction lentling agency 1or the periormance of 1he work for which this permit is issued(Sec.3097,- pERM1T FEE � -" � (Sub-Totaq � ' � � - - - Civ.C.�. PLAN GHECKING FEE � � �� - -- - - - Lender's Name � PERM17 ISSUING FEE- � - ZO O � � � - - � - Lentler's PAdress � I certiFy thaf I h�ve read this opplication and state that ihe above .TOTAI FEE . . . 142,1(y ..-. .. - . _.._. _ . information is correct.I agree to comply with all Counry ordinances �, and State laws regulating Electrical wirirg, and hereby au[horize . . . . , . _ fepresentalives of Ihi9 County to enter uDon�he above-mentianed erty or inspection purposeS � � ��`�M^rn - SEE REVERSE FON E7(PLANATORY LANCsUAGE - � -- � - ll/ �L 7> 7 Slg uft;ot � �ate � . « .. _ ":� . _� i� . `, r. :�, „ . . , j , . � ;!'': , r , . ., � ., . �__ ._.... ,.._. _ . . .._ ---._ .... ._ .__.,..__ _, __.,. . -• �--. -----�- _ _ , ,.. ,,.. . . . _. � � -� . -- -���� �" �APPaOVALS�� �--�-DnrE �--, ir�svectoas� = � �-�� _ ; -- - - ---OWNER-BUILDER�DECLARATION� _ - , ..; . . sICNATURE -- -.. . ._� -- �--.. . ._. ,. _.. , : . ' _, ._ _._� _- . . . . �.' . �.;l.P: . . '.'I �.__ . .__ ' . 1 . . . ' � ��.,`. �� TEMP.PO'NER POLE� -r .:�,.� ' � � Law lor��hcr lollowirr3 eason(Secliont 7031n5ac�tou5��ei�� �,. . _ .. . ____ � . �,. � UNDERSLAB VlORK � - I . �._ . .-__.. ._- _. _ _._ _ _ _ .._ '.�� � � .��� -�� ' '. Prolessions Code):Arry city or coi,nty wh;ch requires a permit �— --- � , ;- - ,-- - -�- . � .,���� ' � - � !o eon.^,Lvct,altcr,prp,rovq dCrtlolish,a-rcpi'ra.oystnicq,re,priw � ROUGH CONOUIT - '�---�" - - �- -� ' ' ' I �� � � - _, � ; ` ,' . �' � � �- �� ' �� ��" � ��'�io!ts Issd�ncc;'also rcq�.�ires fhc�plicarrf for such perm�t�to(i�r' �__... . �-'�--��--,-- �- �VdIRING '--�---�- ��/.� `�� ' , ,. �, . . .. �� a signetl statemern thoE hc is licensed p�rsuant to the praruions 1 "� _ ,, . . � � � ol fhe Contmcfw's Lkense Laoi lCha,�tc�9(wmrnencin�wifh `� _ ._..__.. ____.._: . FlXTURES - ._ ._ _ ' 1� ._, �� �� ' �� -��� - � -��- - ���� � �. , : : �"Section 7000)of Division'3 0/the Etusdacss antl.Pro/essi0ns �. L --�.',. - , � '�--'- �--�� -�-- -- �PO4"1ER�RUTHOR2ED-:-:. "�-- � � -��"---- ���" ��', � -- '� �� � CadeJ oi th�!fic-is exe.mpt'fhemfrom��and�fhe b..�sis larr, ; . � � - aac,ed excmption. Any viWation o/Sectian 7031.5�by�arry � -.-.- _- --._- ......-.. UTILITV GO.NOiIFIE� - ' : � , licant for a npp permit 5uG(eets the app!ican(!o o�ayf prna7ty ; ._____. . .___._._._. .._ .FIPdAI-.__......_ _ ffltCl'OI2.T7'OIIt�__. � ._ . ����.,� � .� ofrrotmom[hanGvchundredCol�ars(55001: �. . . ;� � � � ' ��, j ❑I,xs owner of fhe property witt tlo lhe work,anq the '� � kO7ES__ .__ ' i, '� '. � � ,...... , . , f Struclure is not intentled ar olfzretl Jor 531e. � ... ..... . ...._._.. _ . . ._ _ ._ .. . ._ .._. ._ � . � � .� - . , � � � � (Sec.7044,Business antl Hof�sw'aos�Coder'-The�Conlr�� '. i' ' ' .. : . . ... . � - - , � �.., . ,„. �,,; �_� , I , � � License La,v does nof apply fo an ovmcr ol prq�cny who Dui;ds �:.. __.__.. . . ._ . . ..�. ..__.�. .�'_'_--._ ..,� ; �, '�� -.__ . '. ._._ . _...� � ; � pr Gnprn�s thereon,�and ivho tloes sueh�rork him;eN prwidetl ...� � .... .�. . . , , , , . ., . ,, , , �� , Uia:such irnprovemen;s are nof intcndetl or o(tcrCO for sale:�lf, , I .'�... � . . . , � , . . . _. .. ._ ._. _. . ._ . __ . . . � - _.. �.��'� , howcver,!?�r hullding or improvemcnt is sold within onc ycar ol . . . .. . , ___ - ___ . , . _ . ._ .. � , . . � . �d ! f . . . . .. .. ... __.__ .. _ . . .. , , ''c P ^ at .. . . . . � mA P�p � P��th l.....__._.._ ,. .._ _.. __..___ ....�_._'_. ._. �. _. . � .... ! ' �h tlid nof build a f r bmva lor Ihe,Vu rose v ale.) r..�. . . . �. i , . . . . . - -� - � - + - - '- - � " .,. , . . . , . . _.. ., .._.� � .. . . .. , ..._ .. _. _ . __ . . . . . . , .. __ . ----._�_. .___.. . .__.. ' � � ' � � � � ' �I am exempt under Sec:��-" - � • ..: � .. , . . . .., _..... : . .... ,.. . . �- , � � ' ,-�� , :.". . .... , , - . --B&P.C.for this reason ' �� ,. . _ . . : � „ ; ...� r -- --�� - �----.. . ;_..� . ...... . ....... : . . ,. � , �.. . . . . � ._Date ' ' - ' , . . � : Ol•mer ,. .. � � •^ . � --` �, ._� _. . �..... , . ; ; � _ : .. ; . . . - , .. , , ., �, ., ._ ., �.. ,. , I.__ j __i'{ _� , . � '--. _ _.._. � � , . . �� r. .i . _