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HomeMy WebLinkAbout1749A _ _ ` _ i � OR ER O PENSATION DECLARATION 76A663 IOiB� APPLICATIpN FOR� ELECTRICAL PERMIT � I hereby affirm Ihat I hove o cer+ificote of consent to self �E'�G ' . insurc,or o cer�ificate of Workers'Compensa�ion Insurance, � COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy�hereof(Sac.38 y,� b.C.) - . ��. POolicy NO. Company 1 � � FOR APPLICANT TO FILL IN - 10B r Certified mpy is hereby furnished. New Residential Bldgs.8 Pools EACH h10. - FEE ADDRESS - J 2� G � 'Q �D ��, � Certified copy is filed wi�h the county buildin, ins c- 1 8 2-Famlly,Sq.FL � — S LOCAUTY �yt�OV1 V tion department . . i Multi-tamlly Sq.FL — �NEaRE57 . Residentipl Swlmming Paols � ' � O�R� Y. V � V { . : Dote Z�APP1icoM . � : ,� � � � FIBM NAME C � ' - - CERiIFICAfE OF E%EMPTION FROM WORKERS'� � � � � � qDDRE55 � - COMPENSATION INSURANCE � Oudets:Re.c Light Sw. , Thh�oction nead nof be com Ivfad if Tha work lnrolved 6 �� - First 20 � �,0�� �� � P y Towl No. CITY Tel,No. iha permit li for ona hund?ed dollan(5700)or len:) Additional V. � I ceNify thot in�be performance of the work�for which this � . -� PPaNiCnNTK ' . permit li issued,I sholl no�employ any person in ony manner I aa os to become sub�ect to fhe Workers'Compensmion laws. Ughting Fixtures �First 20 ADDRESS � - .. . . . . . � To�al No.� . Addifional CIiY - Tel.No. � Dafe appli[ani � � fized Applionces Not Over 1 HP RMIi NOTICE TO APPLICANT: If, after making this Certifica�e of . AP��A� �1� � Exemption, you should become su6ject �o fhe�Workers' Ronge_Heafer,rD.W.— � � . Compensotion provisions of fhe labor Code,you must far�h- Oven _Dryer _W.M.� ADDRE55 S ,e� 1 . wi�h comply with sucF pravisions or �his permR ahall be Top. .—.FAU —W.H.— , c � deemed revoked. � �. � � Hood _Fan ._Other_ � � CITY �'� � �Tel.No. j� ��� LICENSED CONTRACTORS DECLARATION - . Disp. _Room Air Cond. — ���N��R �t . Class. '� ', I here6y affirm ihot lam licensed under Qrovisions of Chapter 9 . REG.NUMBER . . (commencing with Section 7000)of Division 3 of tha Business � DISTRICT NO. PROCE D BY and Protessions Code,ond my license is in full{arce ond effecr. P°`^'Br Apparatua&Large Appliances . . � �O . .. . , � �(����1 _ .�. � Size 8 Type HP,KW,KVA,�or KVAR- .. . . . U - License Numy6�er T � tic.Class� �IJp to i Incl. FINAL t ''i,1 `� Date�Z'0� . Over 1 to f 0 Inci.. . OATE �E : � YALIDATION Q ' Conlractar J�'(L (� �� Over 10 to 50 Ind. �- .. � FINA � ~ � ❑ I om exemp�vnder Sec. � � � - Over 50 fo 100 Inc.. BY ._. , _ � � 8.&P.C.for Ihis reason - �e`}� . 2 - �a�e:- � � - � � Se�MCC&Panelboards . . . 0-200 Am Under d00 V Signature - mp.Under 600 V � . . � � - � � ❑ � � � . . Over 1000 Amp.or Over 600 V . . . . .. .. . Ezemp�ion for Reg.Maint.Eletf. SINGtE FAMIIY � Temp.Power Vole 8 Appurrenonces I � HOME OWNER-BUILDER DEtLARATION Sign with One Bronch Circuit ! � I hereby affirm�hat I om exemp�from the Contractor's Licansa Addirionol Sign Bmnch Circuin . .. ��_� 7�(J.9 A I �� Low for the iollowing reason(Sectian 7031.5,Bosiness ond � � Profassions CodeJ: . � � . . �. - � � �•��,� � � ' � � . � Misc�Condulfs 8 Condvctore � - � � -� � � -�� � �i I,as owner of rhe property,will do ihe work and Ihe � � atrucWre Is nm iMended or offerod fo/sole(Section Other(Sae Camplete Pee Schedule)_ � � • •$�.5 Q'., . . 7044,Business ond Professions Code). � � ���� �3 1,50�� . CONSTRUCTION LENDING AGENCY . . - � - . � . -- . . . I hereby affirm rhor rhere is a consrruciion lending agency for , O P.Z 7�8 A�i fhe performonce of the work foi which this permB is issued pERMIi fEE - � � (Su6-Total) Q � � . ��� - � � � � � (Sec.3097,Civ.C.]. - . � . � � � PLAN CHECKING FEE - � - - -� � - . . . ._. . ..... ' lender's Name - � . � � . �� . - PERMIT ISSUING FEE . .. . _ j ,, . . . � Lander's Address - -- '` . � �, 1 cerfify thar I have read ihis applicorion and arate fhat�he TOTAL fEE �jV - , - ' � above information is conect.I agree fo romply with all County _ . � ordinonces ond Sta�e laws regulating Electrical wiring,�ond ,,, - � � , ' here y outhorize represematives of thia County ro emer apon . . � . � � - . � - � � - - , ' ih ove- ntion d praper for'nspection purposes. � '� ; `f ��� [� _ � �'�q_�`J SEE REVERSE FOR EXPtANATORY LANGUAGE �z �� �J �4 �igna�ure f Permiiiae �ote � � � - - - _ _ _. _._ _ ____--- - - -- . _ . " � - _ �� � ���r,�� � ��� "` .�.. :..,�. „ . .,..r.�, ,.�e � �` ,��. :,... . �.„.... , < - z. _ - :--•�,� rrr'�■�lM� ��.�-,-,r........ ...,.��":. , � ., .... .. .,... ....._ . .... ._.. .. �._..- . . . . ....,-,.._. .. '-�. -.� '.el.,.��x. :�. ,.� � , �r .APPROYAlS �-. ;� ➢A7E - .�SIGNATURE �: ... ..... . . .__.. . .�.. ". OWNER-�ILDE�,O�Z41Y�.��T r� ,.. . `--. ._.� ... �, ,�P.,.��Q��., .;.. ._... ..._.........; � ,�� .;:.i' -�...�� '�. � � I hercby affirm fhaf 1 am exempt from tAe tonfrocfora , . .. _ .. , . - . ..' .--". .. . . License�.Law.for the.following reason.(Sedlon 7031.5, �_ � �,,� ��, UNDERSLAB WORK � �� . , . _.. � �.�_,... .....�_ � . �. . ' � �-BuslnessandprofessJonsGod4):.AnyN�yorrounfywA)cb a. . ._ _.._�. .. ._____ . . . ' " ROUCaHCON�UIT � - �- ��- '- '-�� ^" '�.- - ` '.� Nqufnsaps'rm(fto.�onstruci,olf�r�fmprove,demollsh, � � � . . . _..../.��;'-:- � � , �� or�repalr-any�atrueiure;prtor to us lssutince,also�re- . .. ....__`-_ � . J. "� � WIRING � f � �qulnrs}hs ppplfehnY for such permlf fo llfq q sfgnedstaee- ,�- � ,�� ' �� FIXTURpS �,�' ... '.��� % , ,;.�: - ' �� ' '�� menT fha}h8 7�Ilean edp nuonf la iRe pfovlsions f fbe . s u o ;�. ' I�� � ������� ���"-��"� � ,� . ..�.'ContraNar'sLlwnsaLaw(Chppfer,4.{cemm�naingwtth. � � L._ .._ _...____._.._. p��R AUTHQRIZED .... ...-. ., � ------ �.,�..,�� . . .. . ��,:.�:,� :; � SecNon 700Q)of.DiW:lon 3bf�.:f�e Business�a�d Proles- �-- .---.-.....-._.....--._--�UT7LtTY CO.NOTIFIED .�... �� . �- . . � �� . _�.�stons Cod6)or�fhathe is exempl therelrom pnd fhe bosis . � ' � � �� �for the.qfleged�exemptlort..�Any yblatfon�of�SecNon - e7.__ .. . t.� .,�; � '-.� :, �. -J031.5 by�,any.oppHmnt for�v pa�mlt s�b�acts�tha appll- '�.. ... ... . _.._:.FfNAL--.. . . .. _. �hl�or on JroRI � . . � , - " " -' �' ,�. tanf}o o c7v11 ptrnafty of noh more tFon five hundred . � ..�_.�, ,- . ° . ......_ .__ ._,NOiES . _ :,� . .:.: - .: � - � dollaC7.t,asownerofthe ro'... . � ,. _ �" ).__.._. � �: ' ' , � � � � � ' -� �� . .. p perty will do-�the work,ond . � .._........� .. ��'. �� • " ......:� .. ' . .., ' .._- �..'�, . .. �.. . .1he ehucture ia not intended or offared for sale...-. . . . ;. � '..: : �' " ' ` � '-i � � . .- . � .,-�- .'. �' � .� ��. -(Sec,�70/4..BuslnessandProleaslonsCods: ThaContrac. � .___. __ ..__.- ., ..._. . . � . � �� : ��- .= ---�_ � �^- - ' . � for s fleenee!aw does nof applyio on owner of�.property ; - ;... ` :�'=-. ' .. �_._ _ � ._..r •� ',� ' ', .. �.,,���..: . � . ' who builds orJmprovea fhareon, and who does��auch . " � . � - work hlmielf provlded�hdt-rbch Improvemenfs are nol . . -.^........ ". ...-.�.....-,�-- .. '�,.. . -... ' "� , ,., : . . �- . ' . y < � Infendudorofferedioraalerlf.howm�or.thebulldfngor , � � � � ��Impravement is seld wlfFin�cne�year of mmpletion;the .'� . ....-•. � . ., . . �. . � .,,.�, � ;: ewner-6utfder vLlll have Ihe 6urden ei p�oNng fRat he dld �, �.. .._._. . ...__. _. .� • ..:... ....... � � :'� .. . ..•�� .. <.:� �... -,. . � .. nof bu7fd or 1/rtprove ler fh4 purpose of sale.) . � . . , , , ., ni �, . - . � . ... . . . ._ .�... , ,. . . . .. . . ..._..: . �..,- : ; ... .. . � ,., ' _ �_ �...,. .L:� . _.. . . .. �.,� r , .. ....... ....__. . , _. . IartibxemptunderSeC`(,.., : :Ji'e :�;���� , ___ , ! _..., 8&.R.C..#or this reason..- .. , , _ _: _._ J ;._... .. '', � _ _,. s _. _,. . .. , , _ _ ___ _- _._. - ___ _.: , , ,.+ _ .. . _ ._ __ :__, . ., _,� , , Date- ,, , , r -. __.. � �,.;.. , o, � � . � � . I Owner ' � � . � . ;. ,..., � ,. . .. . .. � :. , ., . _ . . ....._._._ ...__. .._ . . ... . . . � � .. . � . . �i- � . . , . . . . : .. ._. ...._ ..: ........ ._.... .__.. . . .. .__.__ . . ,.; . .,..;�, ..... � . . � � � .. ' � .._ . _ . . . . - ... . .. .. , .. ... ,. . .. i . � . . ,_ _. ; ... . , . � ., , . , ...... ..,. ..+. . ' � � . .. ' . . . -. . . . .. .. ,.. , . , � .. �.. . .. ....... .. .. .. ... ._ .._........... _ . . . ,....... ... . . .'I . . . . � .. � � . . . . . . .. . . ,,, .;, _ ,.. . . .: .. � � � '. .. . .. ,. ., f ��, {� F'; -