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HomeMy WebLinkAbout1620A (9) WORKEFS'COMPENSATION OECLARATION �� 78A683 �o,e, APpLICATION FOR ELECTRICAL PERMIT � I herehy aftirm tha[I have a certitiCate a(con5ent to seif insure, CEBo6G or a eerti�icate ot Workers'Compensation Inswar�ce,or a certified COUNTY OF LOS ANGELES T� L+3� �BUILDING AND SAFETY copy thereo((Sec.3800,La6.CJ � P�all(?/N:r '��7-�9�.pmpany �iC�� FOR APPLICANT TO FILL IN ' � JOB Certified coOY is hereb furnished. EAGH NO. . FEE ADORESS 09 � �, Y New Residential Bldgs.&Pools � Certified copy is tiled with ihe county buildirg inspection 1 8 2-Family,Sq.FL S — $ LOCAIITY � � � tle ariment. � � Alulti-lamily Sq.Ft. — nEnaEST �n Residentiat Swimmi�Pools C�oss ST. � Date Applicant p��� OVM[ROR � FIRM NAME - CERTIFICAtE OF EXEMPTION FROM WORKEFS' Mnil Ou9ets:Rec—LIgM�Sw.— ZB COMPENSATION WSURANCE ACOReSS (Tbis section need not 6e compialed N the work Involved by lhe First 20 permit Is tor one huntlred dollers($700)a less.) Total No. Addltional CITY Tel.No. I certiy that in the perlormance of lhe work for which this permit P�AN CHECK � is ISSuetl,I Sh811 n0t 0rt'pl0y any person in arry manner 50 23 f0 APF'UCANT become su6ject to the Workers'Compensation Laws. L'yhting Fixtures First 20 ADDRESS .. � Addilion2l . - � Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: II, after making [his Certilicale of PERMIT � Exemption,you should become subiect to the Nlorkers'Compensation Range_Heater_ D.W. _ ArPUCaNT � H�a�C- provisions of the labor Code,you must lorihwith comply v�ith such Oven_Dryer_W.M._ � ADOFESS .7 provisians ar this permit shall be dcemed revoked. ,Tap _FAU _ W.H._ .LICENSED GONTFACTORS DECLARATION � CiTY ���_ � Tel.No. . �Q Hood_Fan _ Other_ I here6y aflirm that I am licensed under provisions of Chapter 9 uCENSE OR (commencing v�ith Section 7000)01 Division 3 of Ihe Business entl DisO� —Room Air Cond..— qec.NUMaER l� ��s G/ Pf01B55ipn5 COde,antl my IiCCn50 i51n fu�l 10fCB dnd eHCCt. OISTRICT NO. PROCESSED BV Powei Apparatus&Large Appliances �/ I' Size 8 Type HP,KW,KVA,or KVAR � � �- License Numbc�Y'/00 Y� Lic.Class �_�� Up to 1�ncL FINAL - -- � � C,O� �/ Over 1 ta t0lncl. DATE �� �. Contractor,��� ��{Date � ���7'�7 - - - 4 VALIDAT�ON � ❑ Over 10 to 501nc1. FiN V I am exempt under Sec. Over 50 to 100 Inc. gy (yt B.&P.C.lor this re�son Ovcr,00 � �1620A (� � Services,Swbd.,MCC&Parelhoards , ' � ^ Date: 0-200 Amp.Under 600 V � � . �2 Signature 201-7000 Amp.Under 600 V � � . �?��O Ovcr 1000 Amp.or Ovcr 600 V ❑ Exemption for Reg.�laint.Elect. . . - . . -. _ . .• • •2�y�j p= U � � SINGLE FAMILY- - � � Temp.Power Pole&Appurtenances �Q� 4—�7 HOME OWNER-BUILDER DECLARATION Slgn with One 8ranch Circuit I hereby aflirm that I am exempt from the Contractor's l.icense Law � Q far the lollowing reason�Section 7031.5,Business and ProfesSions Additional Sign Branch Circuits �,� CAtle): L � fl/ � ❑ I,as owner of the property,will do t�e work and ihe structure Misc.Conduits 8 Gonductors � - � `� � - . � is not inlendetl ar oFlered for sale�Section 7044,Business Olher(See Complete Fee SchedWel_ ► � J \^ � and Pmtessions Code). � - � NI v ' ' " � CONSTRUCTION LENDING AGENCY � - �V �� - . I hereby affirm that ihere is a construction lending agency tor�he pertormance ol the work 1or which this permit is issued(Sec.3097, PERMI7 FEE � (Sub-Total) �S .� - - Civ.C.). PLAN CHECKING FEE _ . _ _ � . . _ Lender's Name � ,l PERMIT ISSUING FEE U Lender's Address �� I rertify ihat I have read this application and state iha[ihe ebove TOTAL FEE inlC�mation Is correct.I agree to comply with all Cpunty oMinznCes . antl State laws regulating Electrical wiring,and hereby authorize reprasentatives of this Caunty to enter upon the nbove-menboned - � - � "- � � - � property tor ins .ction purposes. � . .SEE REVERSE FOR EXPLANATORY LANGUAGE . . . �r-/��'7 , Si a re of Permrttee Date .. �, � ._ . ..�. .. _ „ _. ... ' � ._ . . � . ' .�. . � .. i _. � � . . . , , , . . i _ �, . � , . . ,. � . �i. � . ,� � . ... . .. i. . . � ' - � � . . . . r, r, �_ .,_.. . . _..' _ ....__ ... ....._ .. ." ._ '_ .. _.-_.. �\ � l \ 1 JSPECTOR S � y - � "'`�`Ol NER-BUILOEP.�OEGCARATIp'J ' C �`�,' ._ ..::�,.,.! +•j \r� �PP QVALS _.- �ATE -T SIGNA�URE - . . _ _ _ J�`' •I i ` �, �-� - �.� � -��� -- -� -� � � I hCreDy a(�irm that I nm exempt from ihe GonVaCtor's LicenSe r.G,��\• i;�,TEMp POL^!FR POLE� . ' - - --�---- � --- � � � . Law for the Foilowing roason(Section 7031.5,Business�aad ( . ,UNDE�Sl1c6 WORK -� -- - � � ---'-- -- - - �� � ' Hofessions Code1:�tny ciry a county wh;ch reCuims a permit ,y-____.—.___ __..__ ._ .._ . . _. , ,, .--_toFrorstnmt,rilmr,�imp c,demolish,or7epatit?ny stiucu�e,pnor _�_j .` , flO�IGH CQNDUIT.-. � � , � - - to its rssudnce,�afso re�hies!he a Lcairt la such `�mil fo tile R____....- .__ -. - Q� PP P� ' VJI�iING�1:� - ' _ ___ „ � a signcd shtemcnt fh.i1 hc is hbensed pursuant to thc A������s {--- --� �� ------�'�''� � - . , 01 the Con,7acfa'S Lkerise La�.v(Chapler 9(eommencin9 wiN � , PIXTURES�,� . . . ... _.. .. : ' � i,M:.•„'�.,�'^�'•� �'�� , ' . , � �•Secticn 7000J o(DrYklon 3 0l the Bu§iness trnd Protessions '�� --- ��� � POLYER AUTNORIZED � � ' Cotle) or thot he!s exempf tnciclrom and the'6..�sis fw the , l��-"---"" ��'-""'--"��� �--�" UiILITY-CO.NOTIFlED - ; � � licant tor� Any�violafion o! Section 7031.5 by any al7eged eaemphon. . ' ' . , , , app � permit sub]ecfs IDc apAlreant ro a clvrf pcnafty - ------ ----- FiNn� - _ .lntcr o�t Frorit ' , ai oor ma��r,��r�c n��d�ce uora�s t5soo� ' ,, , '.-_._...__ _.y\�.� _.NO7ES-.. ----- - ' . . .� , . .. , , , ' ---stru[tO I.is not�iNend d'o o Icmd for sado the wark.and[he J, ••.—__._ �•a _ ', ��. , , - �. . . ' �•-�=_ .�`�--�0-1�•.;;-� -� . � � ' � (Sec.7044,Busirmss:vrd Profcssions Cod¢ 7nc Con�uctoi's . __ :�:. . .__ . . �— � „ -� , � License Law dces nof appl to aa rn�mer of prq�edy who bullds � Y ° _-.--- .-_-_ - '':'- . :.._-. _.�_.. ' � '.. .�.. .: . � '��' 'or improves tln:rcon,�.and who tlxs SucD wak himself providetl . , . ` .\.;�• ' ,..,...,.�,...`- j._ , , , lhof sueh improvemenls are nof intended w oltered lor safe.(l, `-. .`.-'•.-'.....-- � �- - - - .. - --'' ' --- � - � � havevc{the 6uilding br lmprovCment is,sOltl wffhin one ycar al � � ..._... .�. ,• t'.. , ._ _ � , . , � , ,. � , _ - .;. canplefion,the o�mc��buirdcr w;7 havc Ihc�burdcn ol proNng that ._._.... ..... . ......._,... .. . . � �. he ditl no!build a ir�rove fa Ne Pu�pose d saic.J , �, ; ._ . . ��_� . �, � ; � � �. L.._ �__ ._._..-__. '_ ____ _ __ __ _____ _ , .. . . _ .�� ' . 1\' �� � :�1� . , �'f - _ _ _. _ ._-._ . . . . . _ � . - . . _. _ - _ _. . , .. ; � -.. ,.. .... i�. : .. ,._ � � � : C.? . :: _- . _- -� __ , �, _.. C'� t`• � � . I�rq exempt under,Se4�� , . . . . ... __ . .._ . , _. . ... .. -.: � . �. _..... .-._ . . . _ : � . , �/„ , _. . .. . ,._ ��,' -�� -B�8�P.C.for ihis-reason .�� . ,.. � �. �.__._ _ . . . � • -- ' - � ---'� ' � . . _. , . ..- -. . . ._ . . _ ... . _ .. � . �--�-Date- - -...-- - . . � � _.� � :� .. , . . -'--- � -- - -- � . . . i � ' � , j . �� , � . � Owner �; t . ,- - - � --- . ,.. � : . : . _ .. , ' .. . � , . �l.�1 {'�,.'t /�. � ' -- - , -- ' ' � . � , . � � - ��6} �;.' � - , 'J�� ' � �., ., , -- ` � � — - — — . �� - �.� 'j � � I . _ _ . .. _ ._. . '_'__._. ___.._ _ __ .. . . ' ���� ._____ � ' . . ,, � � r • .. '�'..'_"'___.. _-__.. ___.��___. "_'__.___._'_`.__ . �� 1 ' - ., � . . i , ... . I�'. .. ._ .. � .. . _ __ " . � ._-_ _.-_ ,_. _� __. � . . . \ 1� __� _ ��i-r:,�?. _-'-� :.��-,��=