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HomeMy WebLinkAbout1305A - � . _ _ _. _. __ - - — ---_.__ _ - ' �! � }� i ••' . WORKER$'COMFENSATION DECLARATION )Cn669 0�01 qpp��CAT10N FOR ELECTRICAI. P�RNIIT"°r,� I hereby offlrm thar I have a certitimre o(conseol to sel CE-806 insvre,or a certifica�e of Workers'Com ensation Insuron� " � ' " "� '� {'^• /' " � or a ten�fied copy ihe�eof(Sec.3800,lab.C.) COUN7Y OF LOS ANGELES E „�: 9 B{�JlLgUI�14Np�;SgF�TY i.''. <'� i .'� U lr` a t... P❑ol�icy No�f�v7�dmpany��1��✓ FOR AI►UCAN7 70 Flll/N J08 � - - Ce��ified copy is hereby furnished. EACN NO. FEE A�DRE55 Z(J� g � New Residenilal Bldgs.8 Pools . � Certified capy�is filed wilh tha coumy 6uilding inspec- �8 2-Family,Sq.FL S — S� IOCA�IT � ��on deportmeM. M�IIi-fomily Sq.Ff. NEARESi � Residenlial Swimmin Pools �R�SS St. Date�� ,r� Applimnt�..�j((�'�,�(,L 9 OWNER OR FINM NAME CERTIPICATE OF EKEMPTION FROM WORKERS' Ou�le�s:Rec_Lighi_Sw._ ��� �. COMPENSATION INSURANCE ADDRE55 p 7 (Thi�wdien nNd nof 6�compf�f�d if 1h�work lavoiwd by Firsl 20 'th�p�rmit is for on�huednd dollan(5100)or le��.) Tmal No. Addiiional QTY!(/ TeI.No. PIAN CHECK 1 cerN/y�hat in�he perFormance of the work for which this ACVLICANT permit is issued,1 sholl not employ any pe�son in ony monner so os fo bemme subjec+io the Workers'Compensotion laws. Ligh�ing Fi.�vres Firs�20 ADDRESS Total No. Additionol CITY Dore °APliw.af Tel.No. Fi.ed Appliances Not Over�HP ffRMii NOTICE TO APPIICANT; If, ofter making this Certificote of nPPtICAM Exemp�ion, you should 6ecome subjett �o Ihe Workeri Range_Fieater_D.W._ Compensotion provisions of Ihe lpbor Code,you musi lorih. Oven _Dryer _W.M._ ADDRESS(� � � i�h mmply with s�ch pro�isions or this permi� sholl be Top _FqU —W.H._ ' deemed revoked. Hood _Fon _Other_ CITY "'�R � ` 7e1.No. LICENSED CONTRACTORS DECLARATION ucENse Oa �hereby aHirm thar 1 am licensed under provisians oiChap�er 9 Disp. _Room Air Cond. _ REG.NUneBER / O Cloaa•G�=v (commencing with Section 7000)of Division 3 of the Business power Apparatus 8 lorge Applionces DISTRICT NO. PROCESSED BY O and Profassions Code,nnd my license is in full force ond effecf. Size 8 Type HP,KW,KVA,or KVAR ,`y� CJ license Number'3L�l�A Lic.Class C''.a(� Up l0 1 Ind. FINAL � � f� Over I to 10 Ind. DATE O Contrauo�i�O. �,t_.d.Date � /7 Over 10�0 50Ind. VALIDATION � fINAL . L.VtI I am exempt under Sec Over 50 to 100 Inc. gY a.� � 6.8P.C.ior ihis reason Over t00 Z pQ�e: Services,Swbd.,MCC&Ponelboards � /� — 0-200 Amp.Under 600 V F� Signature 201-1p00 Amp.Under 600 V � � ❑ Over 1000 Amp.or Over 600 V �� �1 3 0.5 A Exemplion for Reg.Moint.Elect. �• • . . .2 , SINGLE FAMILY Temp.Power Pole 8 Appurlenances HOME OWNER-BUILDER DECIARATION Sign wilh One Bronch Circuit � ' • � 7 rJ O I hereby affirm iha�I om exempt from the Conlractor's License Addifionpl Sign Bronch Circuits � _ Law for the followin9 reoson(Section 7031.5,Business and �t�Z,},�F Q� Professions Code): C CS ❑ I,os owner of�he Misc.Conduits 8 Conductors � properiy,will do the work and ihe shvcture is no�intended or offered for sale(SecGon Other(See Camplete Fee S:hadule)_ , 7044,Business and Proiessions Code). CONSTRUCTION LEN�ING AGENCY I hereby oifirm tho�lhere is o construtiion lending agency ior �he per(ormance of the worA for which Ihis permit is issoed pERM1T FEE (Sub-ToialJ (Sec.3097,Civ.C.). ' PCAN CHECKtNG FEE �Q Lender's Name PERMIT ISSUING FEE � lender's Address • I cer�ify lhoi I have reod this applicotion and s�me thar the T�TAL FEE above informotion is correct.I agree b tomp�y with all Counry ordinonces ond Sta�e laws reguloling Eleclriml wiring,ond ' here utharix represe fo�ives of fhis Counly fo enter upon the ve en� n d pr erty ior inspeUion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ' � /.`�/ ure et Pe�m e Dofe , _.... .. .__. ...�.� _.. �i�E �a. _r� _. .__. ._.. �. ��� QWNER-BUILDER��cCi.PRATIOIV : . . , �AFPROVALS . ._DATE _ -SIGNATURE �� . �- � •�.... ,. _ . . . ._._ .._ ._ __ _ . �� � �- � � � T"cP.1P�FOWEF�FCIE. . - � � -� � � � ' � ' � � hnreby af!irm ihar I am exempt firom Ihe Centractor's �� .' , . '� ...... . '. , . _ . .__ . . ' ' ' . . , licensn Law for thcx fallawing raason (Secfiort 7C31 . -�---�'' ""� � �" � UNDERSCAdVlO^nK - ' 8usinessacdPro!esslonsCode):Anycl�yorrounyw�h � ROUGH CONOU'T . _ .___.. _ '. _. �� � , •�oquUes a Form!}fa censfrucL aNer,Jmp�o�e,demolish. �._._ _'__.. __.___ -... _.._ � ' �..cr�repair onys�rudur+, pr7vr fo Hs'i`ssbancv�,eiso re- . ..---� �--- �----� NlIRING � -"^ - . � qulresfh�appUmnHorsuchperm(tlo(ilcasigned;tafo- � — � � � ment fhai he Is J/cenzedpursucnl lo the prov(s/ons of Ibe ___ . . _ -. . _ FIMUFES.� �." -. - . : �Conlroctor's Lkense Law(Chapter 4,(commeoUng wllF. � ' � POIYcR AUTHOFIZEO= - � -- -- - —� - � � - � ScrlJon 7000)oi D1Wslon.3 0l ffie 8uslness Knd Profes- � . ' , slans CodaJ or fhvl ho Is exompf Ihere/rom cnd the bosls : UTILITY CO.NOTIFI;D !or fho at(egod exempl/on.�Any vlolohon o! Seclion :._. ... .__ __ . .. fiNAI ' �' � -- � ' ' � 7G31.5 6y any oppJlranf for a permit sub!'etfs�Fo appli� �. ..,_.. ,___._ . _ . _ _. ufer on ronl . canf fo a clvll penolfy o/no/more thtrn flve hundreA � - '�� NOTES ' ' � ' � - �- �' � do0ars SSCO.: the struduro is not ir.tended o � ' ' � ❑1,as owner af rho property will do ihc wo.k and - �� � � ' � ..., r offcred for sale. . . ' ' � .{Sec.7044,Business ondF�o(oeslons Codr: TheCorttroc� '"� ' ' �- � � - ' ' /or's Llconse Law doos no/oppfy to an awner of properly � � . /, . - � � „ , � v�Fo 6udd. or�lrr:prcves lhercort, and who does such � -`� � � �� � -- work hirr�selFprovldrd thot such(mp�oJemen's vre ncl � � '' ` "- '�,,,7��< � ' ' � - �- --- � � ---�-- "-- - � � - +nfended or ollarrd far sefe.I!,however,tho 6ullding or . ..'.'- ' " '-. ; � . . � � � � � �� Jmprovemont N sofd�vlLSin one yoar ol romplellon,�he � � . � � � `or:ner-bvifderwlllF.�velf�eGurJenofpro�ingt�anc�d�d - ' � ' � � � � pof buffd cr impro�a(or fhe ourpos^of sa(o,) - . � . � .__ .= � . ' . f::' '.[.\'•.L., . , � `� I pm exempt under.5ec. , , � , ��• ,:. �., . . . , � ;;.�, ,.t•. _ . . ._ . . - . 6 E P.C.fcr this reosoc ~ " __.. . ---. ._.. _ .. . . ,. . _Data � , r - � , - .. � ;y . �, � Ovmer � . . .. . . - �� -- �- � - ---- _ . . �. .1 ^ I _. � . - .. � ��. � _. ; „ . . _+,�\.�,t l ___..