HomeMy WebLinkAbout9462A-; WORKERS' COMPENSATION DECLARATION _;.
1081 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I 'have a certificate of consent to self
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insure, or.a certificate of Workers' Compensation Insuronce,
or o certified copy thereof (SeA31ob -
COUNTY OF LOS ANGELES
B L I AND SAFET
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Policy No.�om
Z
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-' FOR APPLICANL TO FILL IN
J08 1�
ADDRESS210
Certified copy. is hereby
New Residential Bldgs. �. P�r.o�oh�s..,�,,.. ��
- EACH MO. FE E
,
Certified copy is filed wui ding insper
'- 1 8 2 -Family, Sq. Ft.:GCS
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LOCALITY
' Pion epartmeni.
Date Appiic
- MuHi fomlly Sq Ft.
- Residential Swimming Pools
NEAREST
CROSS ST.
OWFIRENA RC
RT�IFICATE OF EXEMORK
COMPENSATIOWINSURANCE -
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Outlets: Rec lig _,.,T
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ADDRESSc� 5A.,t . l:
AOC
.First 20 -
,
-1
+ -
(Thissectionneed not be completed If the work Involved b Y
fhe dollars
Total No. Additional
CITY Tel. No. ?C— g
Permit is far one hundred (3100) or kss.)
1 certify that in the performance t rkfor which this
- permit is issued, 1 shalt not a any manner
- -�so
y - ^�
�NC�NGC
i
as becomes pact to tr nsation laws.
yAdditionalL t.' -
LlghNng Fixtures First 20
Total No.� _
ADDRESS
CITY _- Tel. No.
ote pplic
NOTICEAPPLICANT: If, after making' this -C i raateof
Fixed Appliances Not Over 1 HP
-
PERMIT
.TO
Exemption, you should become subject to the orkers'
_ Range Heater— D. W.
APPLICA
-
Compensation provisions of the Labor Code, you must -forth-
_ Oven —Dryer _ W.M. _ -
ADDRESS
.with comply with such. provisions-or�fhis .permit shall be
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CITY -Q TeL
Na!��j l�+
Hood �. Fon _Other_,
-
CONTRACTORS
LICENSED CONTRACTORS DECLARATION
LIC ORS D LARAon
�D'sp' Roam Air Cond. +_.
LICENSE OR
3(0
Class.
tdhe hereby that l
y provisions of Chapter 9
- --.
REG. NUMBE -
- "
_
(commencing with Section 7000) of Division 3 of the Business
-
Power Apparatus &Large Appliances..
. -
DISTRICT NO.
PROCESS BY !
.and Professions Code, and my license is in full force and effect.
..
_
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License NumberSd�(Y. �Lic. Class'nes
Size & Type, HP, KW, KVA, or KVAR'
'- -
FINAL
fJ
ktZd(k Y g'
Up to 1 Inc,..
.....-,---- - Over 1 so 10Inc[.DATE
�ry "
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VALIDATION i 0
I Contractor Dote _
-
Over 10 to 50 Incl.
FINAL
❑-
I am exempt under Sec.
Over 50. to 100 Inc. ..:
-
BY,.-
Lu
BAP.C. for this reason
Over 100
_
! _
Dat®:
Services, Swbd.;MCC &Ponelboards
® ---•
0 - 200 Amp. Under 600 V
Signature
._:201'- IWD Amp. Under 600 V-
ION Amp, or Over 600 V
Exemption for Reg, Malnt. Elect.
-'Over
- --
SINGLE LY
- Temp. Power Pole &Appurtenances
OWNER-BUILDER
ConirOaNtor
Sign with One Branch Circuit
irmrn
1 hereby i lice
Low for the following reason (Section 7031:5, Business and
Additional Sign Branch Circuits;99462A
.
Professions Code): -
`- -
# • • r .',•
'0 I, as owner of the property, will do the work and the
Misc. Conduits_& -Conductors
( ° 1 09.7b
structure is, not intended or .offered for safe (Section
Other (See Complere Fee Schedule)_
7044, Business and Professions Code). -
011.-
♦ • , C Q. 7 p x
' CONSTRUCTION LENDING AGENCY
' f hereby affirm that there is a construction lending agency for
. I Q Q 7 —8 3
,. - the performance of the work for which this permit is Issued
PERMIT FEE - -• - -(Sub-Total)
(Sec. 3097, Civ. C.): - -
-.
PLAN CHECKING FEE
Lender's Name
'-
- PERMIT ISSUING FEELender's
-
Address
I certify that 1 have read this application and state that the
TOTAL FEE _":_
�- 'on is correct. I agree to comply with all County
above
State laws re sting Elctrical wiring, .ande
`
represent es of this County tc enter upononed
A7in
Pr ty for inspection purposes.
Y
SEE REVERSE LANGUAGE
FOR EXPLANATORY E
Signature of Pera Dat
- -
Vesser + 'i.,:+r a -e.pr.in-
. l ,k "VImo mabeamB - ----* a rte...+: r elm.
We r/r die
t,.,, IA,PPRQVAL5' - .DATE IRSPECIMS
SIGNATURE .:
TEMP. POWER POLE
UNDERSLAS WORK vN
ROUGH CONDUIT;
WIRINWIN JAP
G
FIXTURES
POWER'AUTHORIZED .__ ...
UTILITY CO. NOTIFIED
P(+ c� -
FINAL -._ 'Gx�ar on 5-.1 _.
!OWNER -BUILDER gECIA TI
c... I. hereby affirm that 1 am exempl from the Contractor's
Licensee Law for the following reason (Section 7031.St
- ...... �' - Business and Professions Code): Any city or county which
requires'a permit to construct, oller,.Improve, demolish,
_ or repair any sfructure,'prlor to Its Isluance; also 're-
quires the applicant for such permit to fire a s4ned state -
mem that he is licensed pursuant to the provisions of the
Contractor's.Ucense Low (Chapter 9 (commencing with
- - - Section7000),of Division of the Business. and Profes-
sions Code) or that he isexempt therefrom and the basis
for the , alleged exemption. Any, violation of Section
- . 7031,5, by any applicant fors permit subjects the opph-
- cant to. Nvll eenelty of net morethan five hundred