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Home My WebLink About1735A (10) � WORKERS'COMPENSATION DECLARATION �o�ooroorw3ie� qpp��CATION�FOR ELECTRICAL PERMIT O I hereby offirm that I have o carfificote oi mnsent to nelf ��gp�p� insure,or a certiifmte of Workeri Compens tion Insuiance, COUNTY OF LO$ANGELES DEPT.OF PUBUC WORKS or o ceriifie�d�c�o�py�th��eof(Sec.3800, a � . � � Policy No,! ' COmpany FOR AVPUCANT TO Flll IN JOB � �Ceni{ied topy is hereby furnished, ' � New Residenlial 91dg5.8 Pools EACH NO. FEE ADORE55 ' Cerlifi d co y is filed with the couniy huilding inspec- 1&2-Family,Sq.Ft. $ — 3 IOCALITY J Q � � �lio part 1. Multi-4amily$q.FI. — NFAREST CRO55 5T. Dote �` � Applicont � ' �'2 Resideniial S imming Pools pWNER OR FIRM NAME CERTIFICATE OF ExEMPTION FROM WORKE " Outlels:Rat�light—Sw._ �'�� COMPENSA710N INSURANCE Firs�20 �-� � Aooaess ' (This s�cfion n�od not 6�tomplet�d if 1h�work Involr�d by Totpl No.� qdditional CITY Tel.No. th�pvmit Is For ono hundnd dollon(�I00)o�I�f�.) PtqN CHECK I terlify that in Ihe parformance of the work ior which this ppp��qN7 permit is issued,I shall not employ any person in any manner �� h�in Fixtures First 20 ADDRESS � so as to 6ecome subject fo the Workers'Compensalion Laws. 9 9 � Additional Dore Applicant To�al No. CITY Tel.No. . NOTICE TO APPLICANT: If, after making this Certificate of Fized Appiiances Not Over 1 HP pERMiT ' Eaemptlon, you should betoma su6ject fo 1he Workeri R��9e— Healer_D.W.._ , AOPUCATION � . Compensotion provisions of the Labor Code,you most forth- Oven —Dryer —W.M.—. , ADDRESS with comply with such provisions or fhis permit shall be Top —FAU —W.H.-- � deemed revoked � CITY /�^ Tei.No ''� .t'�j Hood —Fan —O�her_ LICENSED CONTRACTORS DECLARATION � uCENSE OR I hereby affirm that I am licensad unde�pravisions of Chapter 9 ��SP' —Room Air Gond. — REG.NUMBER �'7� Class. (commencing with Section 7000)of Oivision 3 of the Business paWer Apparatus 8 large Appliantes ' DISTRICT NO. ED BY Y � ond Profeuions Code,ond my licanse is in full farce a d eHect. � � C d � Size&Type HP,KW,KVA,or KVAR p �, � 0 License Nvm r �� Lic.Closs Up l0 1 IncL FINAL � V ContmUor Da�e Z- Over 1 to 10 Ind. DATE VAUDATION � ❑ � Over 10 to 50 Incl. F.. FINAL U I am exampt un Sec. Over 50 to 100 Inc. gy w 8.8P.C.for this reason Over 100 p. , � Services,Swbd.,�MCC&Panelboards . z � Date: 0-200 Amp.Under 60p V . — Signature 201-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V ^ Exempiion for Reg.Moint EIetL ' i , ; ��, SINGLE FAMILY Temp.Power po�e&Appurtenonces HOME OWNER-BUILDER DECLARATION I hereby affirm thot I am exempt from the Contractor i License Sign wi�h One Branch Circui� i�° ' • • `2 Low for the�following reason(Section 7031.5,Business and hdditional Sign Bronch Circuits � < < 1 �`� Professions Code): Misc.Conduits&Conduclon @ � � ��T ❑I,as owner of the property,will do the work pnd the � � � � '�` ' � strucWre is not intended or offered for sale(Section 7044, ��her(See Complete Fee Schedule)— , Business and Professions Code). ��' � �—'�'�' ��. CONSTRUQION LENDING AGENGY I hereby affirm that ihere is a construclion lending agency for � the performonce of the work for which ihis permit is issued PERMIT FEE (Su6•Totol) (Sec.3097,Civ.C.). ' �,.�'�� PIAN CHECKING FEE �� ` � �'I..✓ �.7+ Lender i Name , O � �\ PERMIT ISSUING FEE �. lender's Address �� I ceriify�hat 1 have read this applitafion and state that the TOTAL FEE �L j� �,/,/��'� ' a6ove information is correcf.I ogree to comply with oll County . ' ordinances and State lows requloting Elet�ricol wiring,ond � , hereby aut nze represeniotives of ihis Couny to en�er opon : �� the abov�entioned propeny fo=inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE � � �' /2 �� Signature of Permitfee Date ' I nPPFOVaLs DA7E INSPECTOH'S OWNER-BUILDEROECLARATION sicriaruae - � TEP.1P.POWER POLE . . 1 hereby eFfirm tnat I am exempt irom tho ConVactors UNOERSLAB YlORK License Lewforthe lollowtng reason fSectibn 70.31.5,Buslness ROUGH CON�UIT and Prclessicns Code/.�Any cily or counry which iequi�es a perm0 � , � Po construct,alter,lmprove,demolish,o�repair any struclure. W I RING pri0�(o I1S ISSuanCC,ako r2quir25 Ihe a pplicant IOi Such pe�r7iif t� � � FIX7URES , filQ a si�ned statement tha!he!s licensed pv�suant to fhe provF -� � sions ol the Ccntractor's ticense Law(Chapfer 9(c�mmencing POWER AUTHORIZED � wun Seuicn 7�0J of Divisicn 3 of tho Buslness and Professions Code)o�1haP f�e Is exempt therefrcm antl the baslslor the allegetl . UTI LITY CO.NOTIFIED exemp;ion.Any viola�ior,of Section 7037.5 6y any applicant lor a FINAL `nir�ors .}ror.� pCrroit su6jECfs thP BAPfiC271t to 3 CivNpfnelry Of nOt�770fB then , five hund�ed dollars(8500).. NOTES ❑I,cs ovmcr of the proporty w�ll tlo frte work,and � � � thc structure Is not Intendod or oftered for sale. � � . � � (Sec.70.14,Business ard Pro/essions Cod=: ine Contra�ror's � Llcense!aw dces not appty ro an o�,vner of properry who DuilQs or �� Ir^p�ovas fhereon,and who does suCA work nlmse!!providetl that Such lmprovements are not intendetl or'a!lered for sata. !!, � . . frowover,fhe Duildiny^or Improvement ls sold wi!hin one yenr ol tom.p.'etion,the owner-0uifder will have the burden of proving thaf � he d;d nof Gurld or fmprovo lor Me purFose of saie.) I am exempt under Sec � � B&P.C.(orthisreason Data Owner