HomeMy WebLinkAbout1733A ' WORKERS'CO\IPENSATIONDECLARATION 76A663 APPUCATION FOR ELECTRICAL PERMIT �� {�
� . , CEA06G 12�80)
� hereny ateirm tnat I hnve a certieicate ot consent to se�t COUNTY OF LOS ANGELES ' ' - BUILDING AND SAFETY ��
� insure,or a certificate of Workers'Compensation Insurance,ot
� a certitied copy thereof(Sec.3800,Lab. J � �
FOR APPLICANT TO FILL IN ' J08
!� Policy No. Comp�ny AD�RESS
� New Residential Bldgs.&Pools EACH NO. FEE
❑ Ce ified coDY is hereby furni�shed. - 1&2-Family,Sq.Ft. s — s LOCAUTY
Multi-family Sq.Ft, N A
� CeRified copy is filed with the county building tnspection yn Ciioss ST
department. Residential Swimming Pools owNEA OR
-t FINM NAME
� Dat�y��pticant � Outlets:Rec._Light_Sw,_ MAIL -
� FirSt 20 ADDRESS
CtiRTIFICATE OF EXE� TION FROM WORKERS', Totai No. Additional CITY Te�No
- CONPENSATION INSURANCE >'
PLAN CHECK O
APPLICAN7
(This section need not be compieted if the wock invo�ved U
by the permit is for one hundred dol(a�s (SI00)or Icss.) ��9hting Fixtures First 20 AODRESS �
� ' Total No. Additional
. I certify that in the performance of the work for which this CITV Tel No. . �
Fized Appliances Not Over 1 HP
permit is issued,I.shali not employ any person in any manner pERMIT.. W
so as to become subject to4he Workers'Compensation Laws. Range_Heater D.W._' � ' APPLICAN7 a
Oven _Dryer_W.M._ ADDRESS N
� Z
�, Date ADPlicant ' Top _FAU _W.H.,_ � '
Hood_Fan _O[har_ ci7v o.
NOTICE TO AYPLICANT:If,atter making this Certificate of Disp. _Foom Air Cond._ �ICE E ��-
Exemption, you should become subject to the 1Vorkers' REG.NUMBER s
CompensaUon provisions of the Labor Code,you must forth- power Apparetus&Large Appliances DISTRICT NO. PROCESSED Bv
with comply with such provisions or this permit shall 6e ,
deemed revoked. � Size&TYpe HP,KW,KVA,or KVA �a
Up to 1 Incl. �u'��
Over 7 to 1 D I ncl. F I N A L G
, L[CENSED WNTRACTORS DECLARATION DATE (/� r,�' VAI..IDATION �
Over 10 to 50 Incl. v V _
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL"/
.9 (commencing with Section 7000)ot Division 3 of the Busi� Over 100 Bv ,"' r'
ness and F'rofessions.Code,and my license Is in futl force and ����r��
ef(ect. � Services �
� License Nu 6c Lia Class- � S_3 0�200 Amp.Under 600 V � , ,
, ��,-7s—�1 ��`—� 201•1000 Amp.Under 600 V ` .
Con r��� Date_ Over 1000 Amp.or Over 600 V 1 7 3 3 A
HOME OWNER-HUILDER DECLARATION p, ppurtenances • •'• • •
Tem Power Pole&A $�, 2
I hereby affirm that I am exempt from the ContractoPs Sign with One Branch Circuit ��• •3 8.5 0
License Law for the fullowinB reason (Section 703L5,Husi• Additional Sign Breoch Circuits
ness and vro£essions Code): •3 E 5 0 c=i
Misc.Condu its&Conducto rs �'�
', � I, as owner of the property,will do the work nnd the Other(See Camplete Pee Schedulel— �3 0 4�8,2
� structuro is not intendeJ or otfered far sale (Section , . �
� 7044,Business�nd Professions Code). .
, CONSTRUCTION LI:NDING AUENCY
1 hereby uffirm tha[ thrre is a construction lending agency
�� for Ihe performance ot [he work for which Ihis permit is pERM1T FEE (Sub-Totall � '
• issued(Sec.3097,Civ.C.). _ "�7 ! ' '
Lender's Name PLAN CNECKING FEE IOne-Fourth Permit Feel
� Lender's Address pERMIT ISSUING FEE s�
I certify that t have read this application and state that the TOTAL FEE � �Y C�
above information is cortect.I agree to comply with all County .
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enrer upon
t/he a�6ove-mentioned prope ty for tnspection purposes. SEE'REVERSE FOR LXPLAIYATORY LANGUAGE
� �-�i��l �7 � /i:J72�7�—Y c�`�.��_tS,Z,.�- . .
Signature of Permitj e , �Date
� 9
• . o��,;el:-Lvi�.ur.f;nr.c�.na�r�o�
. .:. t!i�_:cbp at:irm�Irit l�am c�emp�from�Lc Cnntz�ctbr's
... .. .. . ._ . .
� � .APPROVALS � DATE ���sNCCToii':: — L•,^cm:� I.u��� fr,r'Ihc folluwin�:rc�nan jSection 7011.5,
, stc�dA7u�te --- ., •;�.anJ Ir<�frr�ionr Cra'eJ: ,�iray ci�v ar co:mn•
• , . . � 7CPAP.POIYER POLE-� - � - �rhir7t'rcyuirr.ti c /�Cr�nt! to conslntcf. c71cr, irn,��o��C.
r "'— .. . . �. d_•�nnlirh, rr rcpcir n^}'tLnrcturc.priur fo 1ls.ir¢�CncC.
- - �"- � ' UNDERSCAD WORY. � � n.ho rcq�!ir�-p fhe eppli�'r.nl far si�dr perm.ir fu filr a
_ � - FlDUCH CO�aoUt� " - - . eigrte./ amtemcut tlrel ke is liecits�d pursttant to tlre
' '... . _ .1 �bVIRWG� I . � . . !"nri;iCns uf d:c Car:lraCtn�'s LiCer.re I.c��•((7:cpfcr 9
� , .' (rnn:r.:cr.cir:t H�ffL $v�'limi i000J`a_(Di�isior, Y-af tlre
` . FIXTURES I . . . � l;:tsii+es'; c.�id 1'rnfi-saior.�� CoddJ or �het h��fs exern�>t
– . � . ���. � _ Il;ercjro�•r nr!a O.e Ln;is fur 7hc p1,9�rrd r.crmpliun.�tuv
, a ,, � . ti - �'OWFR A�JTHD�t�Ze� � riafa;inrt o(Setiinrr i097.?hr m�rcppliccnt forc pcnrrit
UTILIN CO.NOTFiEo I� � � s:th%tcLc tf::�cp;,Gc�crr!fn Q riril��e�r:altl'af�tat�nurC tftarr
- �� � Jirr hur:drcd do;!ars(SS001.: � .
� . FINP�L �s:.�r: 6�- �4CK� � 0 1.a:m•;ricr r�f thc�roPcr[t�t�ill d�fh::c;ork.and
•., • -.�. – � tl�.struc[ure ie not intrnd�.;i or uffrred for sal�_.
NOTES {� (� �
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- ������ {��op;n,r irFra bnild.t'or imprnres thcrrwi,c;rd+rho docr
' . �`�� }, � � � svrh �crnA iiLrisc!( pmcrdcd dmr such rrnrrrovcirienu
. .. . en° rnt iiit��ud�rl nr nff,�red for ra!e�. !f. 6nwr��er. t7�r
�-. � � .. . .. „ lr.:ih!;ri; nr in:?rorcrn_iu.is ruld �ritdiir onr t�car o(
rarnp(.�tia�i. 11:� cirncrhxifder niR l:a�•e the Ltirdcrt
, ,. . . . ,_ . • _ .'�. q` prorii;;• Ihr.t he drd �eo1 h:�ild or inrprore for!Ge
. . p,n�^u.�",of anfr./ ,
� , — I am e�empt tutder Sec. .
13«i'.C.for Ihi:rc�.on
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