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HomeMy WebLinkAbout1746A (10) WORKERS'COMPENSATION DECLARATION � 76A663 ,o�e, qpp��CAT10N FOR ELECTRICAL PERMIT � I hereby oftirm thai I have a cenifiwte of consent�o self �E-� ins�re,or a cerii(icate of Wo�kers'Compensation Insuronce, OUNTV F OS ANGELES BUILDING AND SAFETY or a certi coPy ther o (Sec.3 ,Lab. .j ' -� � � ��``������ FOR AIPIICANT TO Flll IN ADDRESS C_.. P❑ol��cy No. Compony ' Cert�f�ed copy is hereby furnished. New ResideNiai Bidgs.& ools EACH NO. FEE �� � Cerfiied copy is filed wilh Ihe county b�ild�ng inspec- �8 2-Fomily,Sq.FI.� s — E LOCAIITY tion deportment. Mulli-fomily Sq.FI. CRO55 ST, 1C�,1 7 t'��. .=�r� � '� �_ _S' Residenlial$wimming Pools OWNER OR Da�b� 0 ApplicoM �� � FIRM NAME C CERTIFICATE OF EXEMPTION FROM WORKERS � Outleis:Rec_Light_Sw._ �'�� � COMPENSATION INSURANCE aDDRE55 � � (This s�dlon nNd net 6�eempl�f�d il tM work Involwd by First 20 , 1h�p�rmif L lor en�hundr�d dolim�(f10U)or I�as.) To�al No. Additional ❑T � Tel.No. �I certify that in the performance of Iha work for which this PLAN CHECN [�� ( E� AGPLICANT permit is issuad,I shall nal employ any parson in ony monner so as to becoma subjeU to ihe Workeri Compensafion Laws. Lighting Fixlures First 20 ADDRES$ Add�tional � �'��� ��� � QYD Toral No. CITY Tel.No. Dafe�.�4�1.App�icont Fized Appliances Not Over 1 HP pERMIT � � ��^CE TO APPLICANT: If, afta� making this Certfficote of AVPIICANT � ` ,ption, yoo should becoma subjact lo Ihe Workeri Range_Heater_D.W._ Compensotion provisions of tha lobor Code,you m�sl forth- Oven _Dryer _W.M.— AD�RE55 �"' C� �wiih comply 'th such provisions or this permit shall be Top _FAU —W.H.— ��� � C7��`�.lE'I deemed ra�oked. Hood _Fan _Other_ CITY Tel.IJo. LICENSED CONTRACTORS DECLARATION � UCENSE OR p� n I hereby aHirm thot I om licensed undar provisions of Chapter 9 �'gP• —Room Air Cond. — REG.NUMBERL- a� '.L C�O���/� �,; .(tommaocinq with Seclion 7000)of Division 3 of�he Business power Apporotus&lorge Appliances DISTRICT NO� PROCE BY O ond ProFessions Code,and my licensa is in full forca and effect. , "J � Size 8 Type HP,KW,KVA,or KVAR v'L Litense Number������� lic.Class�� Up to 1 InSL FINAL � h= Q Over 1 to 10 Ind. DATE � YAUDA�ION - � � F�-� CoNmctor ` ��� Dote �'�'�• Over 10�0 50 Ind. - U ❑ FINAL W I am ezempl under Set. � Over 50 to 100 Inc. 8Y 0- B.&P.C.for this reason �°e`�� :-� 7�:�b�� N , Z r Date: Services,Swbd.,MCC 8 Panelboords ► rf • • •2 �.� 0-2510 Amp.Undar b00 V • ` Siqnatvre 201-1000 Amp.Under 600 V � " � � ��l 2 � Over 1000 Amp.or Ovar 60p V o 1 � `. — Exemprion for Reg.Maint Elect. `�•G�' � SINGLE FAMILY � Temp.Power Pole 8 Appurtenances � �.� n—O 5 HOME OWNER-BUILDER DECLARATION T'1�� Sign with One Branth Circvit I iy uffirm Ihot 1 om exempt from�he Confroctor's License Additional Sign Branch Circui�s La.. �or the following reason(Seciion 7031.5,Business and � . Protassions Code): ❑ 1,as owner of the propery,will do the work and the M!�a Conduirs 8 Conductors strucrure is nof intended or offerad for sale (Section O�her(See Comple�e Fee Schadule�_ , 7044,Business and Professions Code). CONSTRUCTION LENDING AGfNCY I hereby affirm 1ho1 there is a consiructian lending ogenty ior Ihe perfarmance of the work ior which this permif is issued PERMR FEE � �Sub•Torol) ��.\ (Sea 3097,Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE �-- Lender's Address � � I cer�Hy that I have read this opplkation ond stme ihat the TOTAL FEE - � L ' o6o�e informofion is correct I agree to comply with all Counry � � ordinances and State laws regula�ing Electritol wiring,and . . hereby au�horize representatives o(this County to enler upon . � the above-memionad roperry for inspection purposes. SEE REVERSE FOR E%PLANATORV LANGUAGE � . , � �2-,fl s�6" � Signature of Permrttee Daie . i � �,. . . . ...... � ..... _ . .� .�. „ . . . � . . . . ' r . � � . . . , , ... . . . .. ......... ........ .. _ _ � . � _., ..-_... .. .. ..:., . ILDER R -. AFPROVALS � DATE �r� �� . , OWNER•BU DECLA ATION , : SIGNATURF�� --- - -- --� --- . . . �--� � �� - - -� " TFMP.PO4VER POLE -�� -� � � ' � � '" � �� � I horeby offirm�tha+I am ezempt�from the Contrac�or�'s �� � .,�, , �. ..� . : � .., .liconso La•++ for.the follawing reason (Soclion 7031.3. _- _ ___ _.._ �'�- -�-"�-----����� - --"-�- UNDEFSIAB 6'JO�K� � - � -8usiness oed Professlons CodeJ:Anydty or county whlch � .raqulrvs.v permi�to consf�ucl,alicr,im rove,demolJsh. _ . . . _-__ .. ROUGH CONDUIT��. _._ . _� .. ' .� _ ��: � � .. . P . . • � . � � � . �� ... o(ropafr any sirocruro,pr�or io n,�rs:�onca,�olso�re- .----` .-� -'.-�--� - � �WIKi�1G - - --�- `� � .� .�� � , • quirvelhnopphcontlors�chpermilfofllcaslgnedsfafo- �� � .. � . � �_ -.'." FI.KTl1RE5 ' : � - � � � -� - � � � men�ehat hc Is Iioansedpvrsucnt fo fhe provlsbns oi rhe � �- �� � ' - --"" . �-�-� � � . . [nn�rador'a Llcenso law(Chapter 9,(mmmoncing wlih � � PO'T;En AUTH021ZED � � . - - - - �- �- -- ' - ' �-- - '� ' '� Section 7000)ol,0ivlzfon 7 0!�bo Bus�ness pnd Proles- � � � � �. , .. . sions CodeJ or tha�hc Is exempt fherefrom and�he basis _ UTILITY CO.NOTIFI:D � : _� ,� (or thc.ollepod oxempflon.�Any vlofofion ol Seol7on � FINAL � ' f' c7 � - � ��`. � .7Q?LS by_any opplltant/or.a permif subjecfs Iho appU� . - -.'-.. .. _ .. .. _ .,.__ __. �.Gulei�on .�'�ortl - �� � con�to v clvil penally oi nof moro fhon Ove�bundred � . _ _..._ NOTFS .� . ' _. . . .. •��...� . dollan(5500)_: . '� . .� � . , .__ .__ __..... ._. __ _ . . .._. . _. � . , -.� � � , .. -- . . . . . . , � - . , . � ❑I,bs owner of�tho propmty v+ill do}ho wor�"�d �iho structure is nol intended or offored for sale.�� , , . . � - . � � . _ . � _ �� , .�(Sec.T044.Buslnrss and Profosslons Codv: The Co��rao- � � � - � ' � for's Lfcnnsc Low docs nof apply fo an owneF oi proporfy. , ._ �. � . �. � . . _ who 6ullds or'Improvos lhereon, and who does sucM � �--� ----�� '--- ' �-- � - � � � �-� � ---�� � ' work hlmseff provldnd thof 3uch fmprovemen}s are net � � � . _ �� � - �- -� � � , � - ' �--- � . � Intended or offered(nr tolv.-il,however.�fhe bulld�ng or � -�" - �� �� - ' � � � � fmpr vemont In�sold wifhln one yeo��of compfetlon.ihQ � ' , - � � � � � ' �owner-bWfder w1U hove fho burden clproving fhathe did � "� ' " ' � noi 6ufld or imprave for tFe purposA of salo.) .� � � ' .... _.._ ... _ . .__. ,,. ; , . _. .._ . _ . � � �•�� - �� � � J.am ezempt under Sec � � . ._.�..... �--...._:'. �. � . .. � - . . ' ; , . . .�. ' ___� _. _�_._..� ' ... ...- � .. . . . , . .__. _. _ . ... . . . . . . - � _ . . �� . . . .._. ..� __. . . .. _ . .B 8 P.C..fcr]his roasor. ` l .,. _ ' • . . __ _ _ . _ __ __. _._._.._ _....- -- + _. _ ._. . ._.__ . � . '_ . :... - -. .-. - _ . . �. .. .. .,. . ' �. __.._6aie_ . . . ... .. � . . � � �. . . � Owner ' . . . , . � . . ___ . .-- ._._ . _ ___.. ._._._ ._.. .._ ... .. ._.. . - . ... , ,. . . . � . ,. . . i.� . . . , , � . � � .� .