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HomeMy WebLinkAbout1749A WORKERS'COMPENSATIONDECLARATION ���� ���8� qpp��CATION FOR ELEGTRICAL PERMIT � I hereby ofi�rm that I have a cert�fica�e of cansenr�o seif � �'� � insure,or a terrifico�e of Workers'Compensarion Insurance, � (� COUNT OF LOS ANGELE$ BUILDING AND SAFETY or o cert�Red copy�h r o4(5 c.3800,lob.C. �i `? �9t ���?'�� �Cy No. ompan FON AIYLICAN7 TO FlLL IN !OB Cerlified copy is hereby iurnished. New Residen�ial Bldqs.8 ools EACH NO. FEE ADDRESS � Cerlified copy is filed with rhe county building inspet- 1 8 2-Family,Sq.FI. E — S �aC�+��TY lion department. Mulfi-fomily Sq.FI. — NEAREST 1 R�y�.�.� Residentiol5wimmin Pools Ceo5557. Da�e�Applicani ������% 9 ; OWNEROR .) , FIRM NAME � � CERTIFICATE OF EXEMP110N FROM WORKERS' OuNets:Rec_Light_Sw._ � � �`'V`�� � � COMPENSATION INSURANCE First 20 ADDRESS I � (This rMion nwd net b�compld�d ff th�work InvoMd by 7otal No. CITY � � Tei.No. th�p�rmil�s for en�hundnd dollars(SI00)or I�ss.) Addilional I certify thot in the performance of the work for which ihis qpp���,�,q�ryjK '�,' 8-� ( '"�='�'� permit is issued,I shall not employ any parson in any manner so os to become subject to the Wo�kars'Compensation Lows. lighting FixWres First�0 ADDRE55 / Total Na. Addilional Date��Applicant �� CITY Tel.No. � ��=E TO APPLICANi: If, ofter mokin this Certiiicote of Fized Applionces Nm Over 1 HP , PERMii -C � 9 Ran e_Heater_D.W._ ' ADPIICRM ptfon, �you shouid become subjaU to the Workers' 9 � Corxipensa��on provisions of�he Labor Code,you must for�h- Oven _Dryer _W.M.— ' ADDRE55 � , ���_� with comply with s�ch provisions or this parmit sholl 6e 7op _FAU —W.H.— / �� � deemed�evoked. ' CITY � `.�c�'fbl.No. p ',�j � LICENSfD CONTRACTORS DECIARATION Hood _Fan _Other_ . � IICENSE OR c� I hereby affirm Ihof I om licensed under provfsions of Chopter9 Disp. �_Room Air Cond. — REG.NUMBER O�1� S�'a{ �au• �rr (commendng with SeUion 7000)of Division 3 of the Business �. DISTRICT NO. PROCESSE BY �' and Profassions Code,ond my license is in full force and effett. Pa`^�er Apporotus 8 large Applionces Q ., '• Siza&Type HP,KW,KVA,or KVAR � U License Numbe�(��"�- Lia Class C'� Up to 1 IncL pATE� �.� �X�A � Date ��=������ Over1 tol0lncl. 3t �`'f .�j VALIDATION F.... CoNractor Over 10�0 50 Incl. W ❑ FINAL 1 em exempt onder Sec. Over 50 fo 700 Inc. BY a; B.SP.C.for ihis reason Over 100 � � z pa�e, Se�vices,Swbd.,MCC&Panalboards� ;'� �L.��' 0-200 Amp.Under 600 V , i; • • • • •G Signature 201-1000 Amp.Undar 600 V . ❑ Over 1�00 Amp,or Over 60p V �. � • � � �;(�z Exemp��on for Reg.Maint.Elect. SINGLE FAMIIY - Temp.Power Pole 8 Appurtenonces . • n � •� `.`)�'-�" ' �. HOME OWNER-BUILDER DECLARATION Sign wiih One Branch Circuit ' � � 1,� 9—�5 I� ry oftirm ihot I am exempt from�he ConlraUor's L(cense � Addl�ional Siqn Branch Circuits � � La.. ior the fol�owing reason(Section 7031.5,Business and Profess�ons Code): � �� � ❑ I,os owner of fhe property,will do the work and the Misc.Candui�s 8 Conduclors ; � � . � slrucfure is nof in�ended or offered for sale(Section Other(See Complele Fee Schedule)_ ► � 7044,Business and Pro(essions Code). � CONSTRUCTION LENDING AGENCY . I hereby affirm tha�ihere is a constructioa lending agenry for �he performance oi the work tor which�his pe�mit is issued pERM1T FEE (Sub-Totol) , (Sec.3097,Civ.C.�. pLAN CHECKING FEE . � lender's Nome �p � � PERMIT�SSUING FEE �I 6 ' Lender's Address � � I certify ihoi I have reod�ha applko��on and,staie ihat rhe TOTAL FEE � . �, above in�ormotion is correcr.I og�ee to tomply with oll Cov�ry �. ordinancez and Stote laws regulating Elecfricol wiring,ond , - . � . hereby au�horize represen�atives oi ihis County ro enler upon �. the obav menlione properry ior inspetlion porposev � n\�� SEE REVERSE FOR EXPLANATORY LANGUAGE t1��G-SS Signoture o ermittee Dale '. ___ _ .._ �... ... . ,,. . . : ___.:.-- ; �.�ehovnis onTe _��Gr�ATU��" _ . O'vb'NER BUIlDER D�CLARATION _ ��..�.�--� . .... '��-.� .�_ TEM,P.�F0INER PO:E. ,. . .. �-�.� ...` . ' �.�.�... . . ....��.. 1 hareby affirm�ihat I�am`rxempr�from iha Contrac+ar's . . ..... ._ . _ . . .. , . . . : f _licenso�Law for 1hn followiny rea=on (SeUion 7071.5. � --- - -� � � � - - UN�ERS(ABWOP.K �. . . � �-. , . - ' .6us(nessandPro/esslonsGodeJ:Anyclryorcountywhtch ;. ., -. •. . reqWres a pormit to conifruct,oltcr,Improve,demolish. � . _ ._ . _ _ _. ...__ . ROUGH CONDU�T � _. . _ _ '_._._ . . �.. � . . . , � � ' � �or ropolr any siru[fure;prlar to fts Issuartca, also re- . �' '- .- . - '. �- . WIRING�- ' . . . . � . .� . . _ . - - qulres Ihe opp:lccnf forsuc6 permlt to ille a slgned state- . �. . � - � - ---� ' . mcnt thct he.la IlcensedpunuonHo theprovfslons ollhe '..______� � : _ .... . . ' fiXTURES.-._'_... .. . . . . ' �, Confroctori Lkrnso L�w(Chapfer 9;(commoncing wllh ..___... _. ._ ., � � '" � ��- �' � SeNion 7000 of Dlvtrfon 7 of�ho Bus(ness ond Proles� __._. . _. _. .._ FOVJER AUTH�RIZED . -- —. . - . ' . ..--�--� � •� � J . . . �� �_ . , ,. slans Cado)or.ihat ho!s ozempt fherefrom ond the 6osis � ' ' � UTI!IriCD.NOTIFlED �' � � , -.-./or tho��allagad oxompf7on.�Any viofaf�on ol Sect/on �.- . -... - .. ... �.-. � . . - ��.. , �� ' � ..;�7C91.5 by any opplfcvnt for a permB subjoc�s fhe oppl;- f FINAL . �i��cr on �rortf _ . . . . . . :�. . �. � - -�--- -- . ..----.. - ----- - � � cant ta o dvll peno!iy o(na�more thcn /ivo hundred � � '� � vO7E5 _' . : . � � ..� � doBors b500.a � : � � �>; �� � . .. --- -- — _--. . . . - . . . . - - - . � . . ... .�I,aa owner of ihe'. . . , . . , �'., � .. . . . - ..... ( , property will do Iho wor�^.d � � � � � � .�thv sKuctura is�not,infanded or offored for sale. � � . .. - , _ . . _ „ . ,. _ ._ �. - , . �(Sea)C4s,pusinessnndProleselonzCodeo 7beConrrac ' �' '- � ,. : ' . . -'_ � � �- '� ., � '. tar's l7c�nse Law doos not eppfy ro an owner o�pioperly , . ,, � � � - � , - , who bu!!ds or�improves /horeon, and who does such � `.'___.-�-_._'- . ......_.__.._ ' . . . �_'.. . . . .. - �.. . �'. work hlmsal!provldnd that such Improvemenls are nol �- ' � � � ' � �-- �-�- ---� �- - � " ' - -" •�•���Jnfended or o!(orod fo�sale.H,howeveq iha bulldln�or� �, �` � �- � � - � ��� �� � . � lmprovcmon!fs aold wRhin'ono yeor c!complefion,fho �� • � � � . ' ��ownor•hulldcrwlU havc fho 6urden ofproJfng fhvl he did _ . . , .- . ; . �, . � , � . ... - .. ., P . .: P P, . sole.) . . no�butld or tm rovc for 1he ur osr of ..'� . ._ � �. .. --. �:_ �,:.__. _ .__.. . ,. . ... ..;- ___.... . . . . ,p . erSec. ' � . � i am oxom t und � �--- - � ..._ . . �, . - ....---._ . . ... ... ' --- .�.. ,� . �, . . . . , _.. . _ . . --..--, � . . ."- .. - - � _...B E P.C..for lhis rcoson . ... �� ' , �' � '- - - -------'..._. � .. �� � ��'•'° ' ' .--. Data.. ... .__ . ' � � � . Owner . . . � �� � �. � i i ._ ._. �- � . � , ,. . . . . .. , ._... _ '. ._'_'.... .. ...,__...__..._'_...—__'___.' � ,.. �,... . . . . . _"_ ' __ _ ' .. . . ., . . . . - i .. .. , �i . ,