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HomeMy WebLinkAbout1747A WORKERS'COMPENSATIONDECLARATION 76nba3 �oiBi pppL�CAT101V �FOR ELECTRICAL PERMIT � I hereby o(firm thot I have o certifim�e of consem lo seif CE-8a6G insure,or a cerlifica�e of Workers'Compensatio�I�su�a�ce, OUNTY OF LOS ANGELES BUILDING AND SAFETV or o cerJi,(ied c`py^t reof Sec�,La-bc.cCv.)� u P❑ollcy No�� J Co pan <�"'t �+ �-� FOR A►►UCANT TO Ftll IN J06 Y AD�RESS Certified copy is he�eby furnished. New Residential Bidgs.8 oqls EAGH N0. FEE � Cerrified copy is filed with the counly bui�ding inspec- 1 8 2Family,Sq.Ft. '``� E — E IOCALITY tion depa�finenf. Multi-family$q.FI. — NEAREST � �� �� ���� Residential 5wimming Pools CROSS Si. Date ��,o„��liconf OWNEROR FIRM NAME CERTIfICATE OF EXEMPTION FROM WORKERS' Outlets:Ret__Light_Sw._ �`�iP'�� { � COMPENSATION INSURANCE ' /+�OREu 1 � �' This��clion nod not b�cem I�t�d if th�werk fnvolv�d b Firs�20 ( P r Total No. Additionol CITY Tel.No. Ihe p�rmit is lor en�hundnd dollon(SI00)er I�ts.) PIAN CHfCK � �.J I certify tha�in the performonce of ihe work for which lhis APPLICANT permil is i55ued,I shall nol employ any per;on in any manner � so os ro become subject lo the Workeri Compenwtion Lows. ll9Ming Fixtures Firsf 20 ADDRE55 / 4�t_�� To1a1 No. Addilionol � Dale 1��`'T�Applimnl < V� CITY TeL No. ��'CE TO APPIICANT; If, aNer makinq Ihis Certificate af Fixed Appliances Not Over 1 HP PERMIT .� � ,,piion, you should become subject to �he Workeri Range_Heater_D.W._ APPLICANT Compenw�ion provisions of the Labor Code,you mus�forth• Oven _Dryer _W.M.- ADDRES � with camply.wifh such provisions o� this permit sholl be Top _FAU -W.H.- .deemad revoked. Hood _Fan _Other_ CIT Te.No.� • � LICENSED CONTRACTORS DECLARATION IICENSE OR /� �hereby offirm that I am licensed under provisions of Chopter 9 Disp. _Room Air Cond. _ RfG.NUMBER ^'t ���� (commencing wiih Sec�ion 7000)of Division 3 of ihe Business DISTRICT NO PR SSED BY } and Professians Coda,and my license is in full force and eHec�. Power Apparatus 8 lorge Appliances O Size 8 Type HP,KW,KVA,or KVAR („) � Litense Number lic.Closs FINAI d' Up to 1 Ind. � Over 1 to 101nc1. OATE .�/ ��� . O Controctor pole �7� VALIOATION F- ❑ Over 10 to 50 Ind. F�NA� �U I am exempt under$ec. Over 50 to 100 Int. BY p„' 8.8P.C.fo�this reason Over 100 N Services,Swbd.,MCC 8 Panelboards ► . 'r� � �'7 F� z � Dafe: 0-2W Amp.Under 600 V . t: • •2 $ignoture 201-1000 Amp.Under 600 V ' Over 1000 Amp.or Over 600 V � o � Q�;,j F � Exemption for Reg.Maim.Elect. SINGIE FAMILY Temp.Power Pole 8 Apporlenances � y � �"t'"�" � ��. HOME OWNER-BUIIDER�ECIARATION Sign with One Branch Circuit - { C.� i—�.S I �y offirm ihot I om enempt from the Contracror's Llcense qddilionol Sign Bronch Cirwits � � � Lo..wr fhe following reason(Settion 7031.5, Business and „ Profess�ons Code): ❑� I,os owner of 1he properly,will do the work and the Misc.Conduits 8 Conductors . structvre is nof intended or offered for sole (Section Olher(See Comple�e Fee Schedule)_ , 7044,Business pnd Piofessions Code). � CONSTRUQION LENDING AGENCY - I hereby affirm thai there is o construc�ion lending ogenty for ihe performance of Ihe work for which lhis permil is iss�ed PERMIT FEE (Sub-Total) ' (Sec.3097,Ci�.C.). PLAN CHECKING FEE Lender i Name PERMIT ISSUING FEE � r Lender's Address � ��. I certity that I have read this application and stoie ihat the TOTAL FEE j Q � . ' above informoiion is correct.I ogree to comply with all Counly ordinances and Sfate laws regvloting Electriml wiring,qnd � hereby authorize representatives of this Couniy to enter upon . ihe ob� ention d pro�eriy for inspection purposes. � SEE REVERSE FOR EXPIANATORY LANGUAGE ' �'1��]e.SLe���—Se�i �d--�CP�J S�gnaNre of 7ermi0ee Dp�e , ,,, . . ..-. ..... . -. . .. ..-... .- ..... ..�.. .. ..' �O'v"lNEP.-BUI!.DER DECLARATION� . � AfPRDVAlS � ' ;_� DATE, t K a . ' � . . .._ • . . � ' .... ... . .. � ' . - SIGNATURE - -.-_ . .. . - -' � ""- ' . � �� � TEM.P.POPlER�PO:E, � --�-�- --�- .' . �'�� � � ' ',. �I horoby offirm Ihot I am'e.emp�from Ihc Controc�o•'s � �� � �. � �-- '. � �. � _ -Licenso low,for the followiny reason (Soclion 7031.5, _ ..._ _._. . . . ._.. ___ . _ ' , �"��- �-- -' ���-� ��--� -� ��� UNDE6SLA0 WORK � . ' � . � . Gusinoss anc�Prolesslons Codo):Any clfy or counfy whi[h '� � ro utres o pormN fo conshud,plFer,Improve,damollsh. , . �_- -.. . - . __...- ROUGHtONC�IiT ' _. . . :__... � ...�, - . • ' q . - � - or repalr ony siruUure.'prbr}o Hs hsupnce, clso rc- .. . .. � . . WIRING- 1��� � . . � � qulres}he opp:lmnt(orauch parmit ro hle a slgned s�ale- � " �' � --- �-� �- � .ment lhcl Re Is l7tenssd pvrsuoN fo fho prov(sions a1 fho ' _.___ _ ..• '.,'..�. �..' FIX7URE5�--_ --' .- . . .Confradori lkertso law(Chapfar9(commen[!ng wllh � � POVJER AUTHOR:ZED'- . - -- - � ��� �-�� � ' " - ` � � Sectioq 7000)of Divlzlon 3 of!he Busirtess artd Pro�ex- � � ' . � slons Code)o(fhof ho Is exempt Iherefrom ond fha 6asis � � ' U7IUT'!CO.NpTIF1ED ' � . ' - � . . !o� 16e oIlagad osomption.�Any vlo!ofion ol Secfton - ._ . _ .. .... _ . . _ FIhA: (' - -� � -- �� . '�� ' � '�� ,7G3L5 6y any opplfeanl lar a prrmlt subjects fhe appll- . _ _ Gn�ci un �ronl . � -------- - - -�-- can}fo a dvll par,aliy of no�more thon INo hwdred ' ' - '.-� NOTES `-, . . . ._.." � doflars(5500).:. . �� . �_..____ _._ . .__.._... . . . �. . .. _. . .-., . . , . . _ _ . � Pr perty . . .. . ' , � . Q I,as owner af iha o will do ihe wo�M'�d . �- ' � . !ho s'ruttara Is not intanded or offered fo�sole. � �, . ��'�' _ � , - . � � 'i . .... �'� . �� .. ' (Sec.J044,DusinesaondPro/essionaCado: TbeConrror - - � ' � � - 'ror's Llcense Law dees not cpply ro an owner ol properry � � . .�,��1 . . . . ' . , . , � who bWids or'tmprovos thorcon, and who does svch � � � � � work hlmsell provlded�fhaf'such�lmprovements are no� � . � � � - --- - �- ' �- -�- � - - � � � � �� inhndedoroNeredforsale,Jl,howeveq fhobuildingor �� � � � ���� �� � � � �- .� �mprovement/s sofd wt�hln one yoor of completion,fhe � , ' - - . � �. "bwnen6ullder wlll hovo Ihe buidon ofproving�halh�did i , , i , . . ....�... .,. �-:, - .. " �� ' � no�bulld or lmprove!or iho purpose ol solo.) . .___.. _._ __. . _..... .. . .� . �-� .. . . , _ , I am oxempt under Sec. , � � , . . . ... �..�. . . . .� . � . � . .__ _ B&P.C.for this roason�- .�. . , � ._ _ . . . . . . , :., ,_ _ . Date-. . _ .. _ _. ......�. � � . � . Owner ' � . .. , ,� � . — � � ... ._ . . . . . . ,.. . ... , _ ' . . . .. , i': , . , .�. . � . . — , ... . , ., . , , ._ _ . _ _ . _ . _ . . .. . . . �, �. . . , . . . �, , . . ��. .. �.� . i . .