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HomeMy WebLinkAbout1236A (6) WORKEF�SCOMpENSATIONDECLARATION 76A6fi3 ,o�B, APPLICATION FOR ELECTRICAL PERMIT � . � I herehy.�irm that I have a certificate of consent to self insure, C6806G or�cerfitica;e ol Workers'Compensation Insurance,or a certilied COUNTY OF L03 ANGELES BUILDING AND SAFETY c`opy ihe�re�oQf( c.3800, ) Policy N9^7���Pany � FOR APPLICANT TO FlLL IN J09 . . � r , . � � AODFESS ( Certitied copy is hereby iwnished. New Residential Bldgs.8 Pools . EACH NO. FEE � Certifietl copy is flled viith ihe county buiWing inspection 1 8 2-Famity,Sq.Ft. $ — 5 LOCAUTY department . . Multi-family Sq.FL — � r�aaesi � - Residential Swimming Pools CROSS S7.� :-Date 1IiTlR°� . Applicant . ONMERDa FIRM NA41E , .CERTIFICATE OF EXEMPTION FROM WOflKERS. , Outlets:Rec—Light—Sw,— ��a� . COM?ENSATION INSURANCE ADORESS '�j rp p � �This aection need not he completM if.the wodc Imolvad by the First 20 � Total No. Atlditional . GTY Tel.No. 6� permft Is tor one hundred doliars(5100�or le�a.) � I certify that in the performance of Ihe work br which ihis permit 7LRN CH K is issued,I shall not empioy any person in any manner so as to � - pP���� become 5ubject to ihe Workers'CompensaG ws. ��'� i ling Fixlures . First 20 ADDRESS Total No. Addilional , Date Appliwnt ' � � .� . CITY . Tel.No. NOTICE TO APPLICAPIT: II, aiter making �hi erYficate of Fized Appliance5 Nat Over 1 HP pearttT Exemption,you shoultl become�5ubject to ihe VYorkers'Compensation Flange_Heater_�.W. _ l+PPLICANT provisions of ihe La6or Code,you musf lorthwilh eomply wilh such � Oven_Dryer-�_ W.M.�__ �- ADDRESS � provisions or Ihis peimit shall be tleemed revaked. Top _FAU _W.H._ CITY . . Te1.IJo. LICENSED CONTRAGTORS�ECLAFiATIOM Hood_ Fan _ Othcr_ � � .2 O I hereby alfirm that I am licensed under provi5�ons O�Chapter 9 Disp. —Room Air Cond. +. uCENSE R Class. (tommencing vlith SectiOn T000�Of�ivi5ion 3 of th¢Business and � REG.NUM3ER Professions Code,and rtry license Is in lull force and effact. Di57Fici n�D. Paocesseo ev Power Apparatus 8 Lsrge ApplianGes �� y^ Size 8 Type FIP.KW,KVA,or KVAR 0.. L�ense Numbei� Lia Class �Up to 7 Incl. FINAL .. . . . . . Over 1 to t01ncL �ATE , a VALIDATfON Contractor C} -Over 10 to 5o Incl. FlNAL O ❑ I am exempt und Sec. � ! Over 50 to 7001nc. gy � � yU,1 6.8P.C.tor this reason Over 100 - p, N Services.Swbd.,MCC 8 Panel6oards , � � n��ate: 0-200 Amp.Under fi00 V ��^^����� -201-7000 AmR Under 600 V ❑ � � - - . Dve�1000 Amp.or Over 600 V Exemption for Reg.MainG Elect SINGLE FAMILY . �� Temp.Power Pole&Appurtenances HOME OL'lNER-BUILOER�ECLARATION � Sign wilh One&anch Circuii � - � � - I hereby affirm that I am erempt irom the ConUactor's License Law for the tollowing reason�Seaion 7037.5,Business and Prolessions _ Additional Sign Bra�h Circui[s �� 2�J.b A Code): . . .. . . ❑ I,ns owner ol the properry,will tlo the wak and the structure " Misc.Contluits 8 Contluctors . . . . �� � ' ° '? is not intended or oflered for sale(Section 7044.Business Othm(See Complete Fee ScheduM)_ � � � �4 a F� And Professions Codcl. . . . . CONSTRUCTION LEN�ING AGENCY � ' '4�.5(i� I hereby af(irm that there is o conslruction lentling agency for the perfoimance of lhe work for which this permit is issued�Sec.3097, pERM1T FEE . � (Sub•Total) �$'��—F'8 Civ.C.). -� . . . . ... , PLAN CHECKWG PEE Lender's N�me � � - PERMIT ISSUING FEE �� LerWe�9 Atldre55 � � � � �� - - � � I certify that I have read Ihis apDlication and state Ihat the ahove TOTA�fEE S � � intormation is correct.I agree to eomply with all County ordinances-� - �� � -- � and State laws regu�ating E�ectrical ntl hereby authwize � representa:ives ot ihis County to upo he a6ove-mentioned � � � � � - � ��- � - . -� - . . .. erty for inspe ' ses. � [� SEE REVEHSE FOR E%PLANATORV LANGUAGE � -�--�i���J _ Signature m p �. ..... .... __ - . ,. „_ . �... . . . . . � _.�. . - �. ,. ; .� � ..�,. ._ . , . . . . .. .. . . .. � _ 4_t 'i-� . , 'n.' ...� __. . . ..:. �.�. .... . � . .. , . . . . . .. � ' � ��.-.` ... �� �`� �.�,�_APPROVALS... . -�----�flA7E� .��....� �si�Na7uaE��� -� -�-. . � --�....... � - -`, ,� OWNER=6UILDERDECLARATION �_, + - � � I hereby aHirm t�a[I am eaempt trom the Contracto�,s Lce��se � _ . ._.. . .__.. . TEMP.VOWEfi POLE .._�.. _ . � _ . .. _ . .. __ . . . , • . . _ , UNDERSLAB WORK. ..,. ..- .... ... - - --. -.� �.. ; � . PiplcssionseCadc)v'Any a o orr couoatny whOi h'reQems aSPerm�f � . . . . _ . . ._.. ____ _. � . . .... ty . r �' � � i FOUGH'GONDU�T•. � � I � .. to eonsLvct,akcr,impiov�,demo'isb,or rcpair nny 5tnicNm,prior -- --�� .— to irs issu.vrce,aiso�equucs Ihe,Eppl.�eant for sucn permif[o fiie ��,� WIRING� � . �. -� ----- --- - � �. a signed sfa.cment Ulaf,he is licertsed pursuant fo�t6e ywlsims ���' .�� . . `^'- FlHTUF[S.. .�. ._ -_. _�__ . � , . . . . . . of fhe Conlixtas�License Law(Chapter g fewnmennng wdh �,...� .�..�'..•:'_�..__ ______ • . � � � . ..� . . , .,`�':-Seetion 700D1 of Divfsion 3 0/the Busirress and Poofessions I P01"J8P AUIHORIZEO � � ' � " Codc) a thaf he is�exempt lhere/rnm md the basis for the i-� � ��� � �� � � ���� UTIIJTY CO.NOT�FIED � � i`�, \. '�9� excrnpDon. Any viol2�ion.of Seciirn 703I.5 6y¢vy afle tl ' _._.. .._..__ . ..._ . . - , ant.fa a pemiit subiects the applicant to a civil�pcnalty �---- ..—--_.. FINFC ----- ._ .�\ . ���rY11Cl'-Ot2�rl'Oftl—��� .. . , , of not mom tha;o five-hnntl�ed dollors(5500): !�-- ._._"'_ :...__._'_'�OTES . . , .._. ... , � . . .. _ . . ❑"_S ... r P P .Y e..Y�ark.and Ihe . - �- I.� Awnef'ol fhe ro ert will tlo th j � S�fUCLL:�13 f10f If1Sc�'1�Cd Of O�I�fE'd}C!S�IL+.� ' . - .- �\.. .'� '.. _ _ .-�__ � , . ' ___ " . _. � � _ _ .� .(Sec.I0�t4,6usiness and Prcfessions.Code: 7he Contmcfdr's .�` ,',..� .. ,. . .... _ .._ . , � _ _ .Licensc l.av docs no[�apply ro an ovme�ot propery w builtls �— � ho ` � : . / -_�. .�•....__�,' . _._._._--- ! . � ,_. ..... . � a irtV�rwes tncrcon.ar�d who tlocs sucn wo/k himsel(p�rn�idetl `'� �� � �_ �� - , �� that suc�improvemeMs are not Ntentletl or cttered fa sala Il, r`' :__.. __. ... . ._.___'_'._1 . .. _ _ � '- `. � _ -� � � � . . .- . -.... � havevcr,the bui�ding w improvrment 1s satl v�it�in ano year oI -., .-. , �� '. -� .".. �; . ,.� _..�. .._._. . _ .. ,.. ._ ..___.._,..- ._._............._ . . CanPfetion,Ehe owncr-bViWcr we7 ha�thc bwAcn o(plaving that � - � -� � � , . � , �. j he�did no(6vild a lmpro�e for ihc F�'R��c of sa1eJ .- � � .,- � i , , . . i � . . , . , . _ , � , . . �.. . . . . � ., . _' ' "'"� ' '_" -'__... __. � _________ .'__._ _ ...... � . � .-�, <.` - _ . . I _ . . . . _ \ ___ . . �.. __ . . .. .. � �_.. . �..t ; -,...�.. j . . ..._ _ . .. , . •. "._ ... .' � '__ _ � ' ' __ _ .•�, � . � . ..___. -_- . .,.--; . ,.� 1 am exempt�nder'Sec ' � � '' � � " � , . - .,_,. .- , _._ .. __ . _ � � ' � ., �, , . , , , --- 6&P.C:�for-[his7eason"- � � ' _; . .�; . . � �� .. . � .... _.... . � ..____.__ . . _ . � �. ,��. -.._� !. . . � . ., '_.___ . .. ...... ... ._ . _._ J �. : . .. .._,. ___. - : .. �. -_ ,�.-.,.�� � . Date �� � .. . . . �. i ' - . . , . .. - .. . Owner � ' -' .. ,. . . ., . . _ _ . . ... .. . . . .�, : ._ �._ . . . .' _. _._, . . � .-� . . . � . ., , � . ' , �. � � , , . . � � � I _ _.__. ._ _. ' I � . ' ' �.. - ___ , _ . E._. .- --._i .._..-�---- -- - - ---- � � � .. � .. .. . � . � �; . , . . . _. .. _ .. . . •. . . � .._._.. .. .._. . . � , , ,. . �.,�, .- __ ___. .... � . � , . , . . . i . .. .. . � • _. : .., �. . �� p � -' ... . _ - � ;� ,!' _