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Home My WebLink About1411A . . - __ ___-- � WORKERS'COMPENSATION DECLARATION �� o�B1 APPLICATION FOR ELECTRICAL PERMIT � . I hereby affirm that t have a cartificate of consant to self C68o6G insu�e,or a ce�tificate of Wo�ke�s'Compenso�lon Insu�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified capy thereof(Sec.3800,Lab.C.) �C�►�i 137o�1q�4 „ Qolicy No. Company��RY��N b FOR A/PlIGN7 TO Flll IN ��b Cerlilied topy is hereby furnished. New Residenliol Bldgs.8 Pools EACH NO. FEE ADDRE55 1 dCertified copy is filed with tha couNy building inspec- 1&2-Fomily,Sq.Ft. �"Yr! S i — S �OCA�ITY � 2 tion department. Mulli•fomily Sq.FL — CR05555T. (� /� Residen�ial Swimming Pools OWNER OR �2H D Dote 2_��Q�APPlicam It�GYL..n..{6 I�R.OwP (7 � FIRM NAME �O i` P CERTIFICATE Of E%EMPTION FROM WORKERS' Outlets:Ret�Light I SN, 2 Mhlt C COMPENSATION INSURANCE �7DORE55 pF� d -T Firsf 20 (This��crien n��d no�b.complN�d if�h�work inreiv.d bY Total No� Addi�ional CITY � �� Tal.No.c��8_C� Ihs p�rmlt h!or ona hundnd dollars(S��)or bss.) GLAN CHECK I cenify thot in the performonce of the wo�k for which thi: AppUCnNT - � permil is issued,I sholl not employ ony person in any manner so as to become subjact lo the Workers'Compenwtion Laws. Lighting fi.tures First 10 ADDRE55 � � Additional 5 � Toiai No. CIlY Tel.No. ' Dme Applimnt Fixed Applionces No�Over 1 HP PERMIT � NOTIGE TO APPLICANT: If, after moking this Certifitate of ApPLICAM � �L,YaN Exemption, you should become subject lo the Workers' Ra�ge_Heater_D.W.— Compensation provisions of Ihe Lobor Code,you must forth. Ovan ._Dryer —W.M._ ADDRESS M ith comply with such provisions or this permit sholl be Top ,_FAU —W.H.— , deemad revoked. Hood _Fan _Orher_ GITY � Tel.No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby offirm that I om licensed under provisions of Chopter 9 �isp. _Room Air Cond. � REG.NUMBER� 3� 5 Claas. Q (commeacing with$ecfion 7000)oF Oivision 3 of tFe Business DISTRICT NO. PROCESSE 8Y ond Proiessions Code,and my licanse is in full force o�d eifecl. Power Apporatus 8 Larqe Appliances �O . � fp . $ize 8 Type HP,KW,KVA,or KVAR Q � License Number ` 1 327 �J Lic.Closs � Up to 1 Ind. FINAL V G,vowP .{. Over 1 to 101nd. DATE 3/�/�� VAUDATION Q Contracto��+�Aµh Dafe ��6�g Over 10 to 50 Incl. FINAL V ❑ I am ezempl�nder Sec. Over 50 to 100 Inc. BY �++ a 0.8P.C.for this reason Over 100 z �ate: Services,Sw6d.,MCC 8 Paaelboards ► � � 0-200 Amp.Under 600 V Signalure 201-1000 Amp.Under 600 V OOvar 1000 Amp.or Over 600 V Exemplion for Reg.Moint.Elect. �1 4 1,1 A SINGLE FAMILY Temp.Power Pole 8 Appurtenaoces - �.• • • • •� HOME OWNER-BUILDER DECLARATION $iqn with One Branth Cirtuit I hereby affirm tha�I om exempf from the ControUor's License qdditionol Sign Bronch Circuils - - � � �8 a 6 8 Law for the following reason(Section 7031.5,Business and Professions Code): � � �• e <E Q 6 8� ❑ I,as owner ot ihe property,will do the work ond the M;sc.Conduits 8 Conduclors � - � ' struUure is no�intended or offered for wle(Section Other(See Complete Fae Schadule)_ , �2�7—�4 ' 7044,Business and Professions Code). , CONSTRUCTION LENDING AGENCY � I hereby affirm ihat there is a conslruc�ion lending agency for the performonce of ihe work for which this permil is issued PERMIT FEE � (Sub•Total) g (Sec.3097,Civ.C.). , . G� �1pQ�6p 4� PLAN CHECKING FEE � - Lender's Name PERMIT ISSU�NG FEE �O Lender's Address �t-171tG2-S l 02 �As � I certify ihat I have read Ihis applicaiion ond smta Ihat the TOTAL FEE g g , a6ove information is correcl.I agree to comply with oll Counly � . ordinonces and Slate laws reguloting Eletlrical wiring,and .__„ hereby a�thorize represeniatives of this County to ente��pon the above-meniioned prop r�y for inspeUion purposes. � SEE REVERSE FOR E%PLANATORY IANGUAGE - ' Z-6—ti`f Signoture of Per in Da1e � --. " , ' APPROVALS � �ATE _ . _ __._, _, OWNER-6UIlDER DECLARATION • - � SIGNATURE TEMP.POWER POLE � �- . ' " I horeby affirm thal I am oxempf from the Contracior's � �- -- - ' � - " • • li[emo Law for iho following reason (Setllon 7031,5. � UNDERSLAB WORK ._ - . 8uslness ond Professlons Code):Any Nty or munty whlch RDUGN CONDUIT � - requtros o permB fo construtl,after,7mp�ovc,demollsh. , _ __, �-or repolr any strVtfurc,prlor to itz issuonco, olso ro- , WIRING , . qulrosfhaappllconfforsochpermlf}ofileaslgnedsfafo- � moni}hof ba is Ifcensed punuont fo l6c provls7ons o/Ihe , fIXTURES � Conhacror's Geenao Iaw(CRoptcr 9(commundng wnh -� � POWER AUTHORIZED � - � � � SoUlon 7000J o(Dlvislon 3 0/Ihe 8uslness ond Proles� sions Cade)or fhaf he Is cxempf}berelrom and the bosls - �'�- UTILITY CO.NOTIFIED for fhe afleged oxempt7on. Any vialoflon o/Secflon �- � FINA� n - . 703i.5 by any applicant for a permtf su6jech Ihe oppl�- , C.nfcr on �ron[ canf fo a clvl!penalty ol no�moro IFon 11ve hvndrod - NOTES - � , dollars(5500).: , � � ' ' ❑I,os owner of Iha praperty will do tho work,ond - � tho structure is not intended o�offerad far sale. , � (Sea 7044,8usln¢ss ondVrofeSslonn Code: Tho Confroc- � �- � ' tor's L(tense Low does not oppfy to an owner of proper�y . _ . , - __ �� who 6uild,or Improvos Ihe�eon, ond who docs svth work hlmsclf provldcd ihal sut6 Improvemen}s aro nof ��- � , � , -� � � � . . � In}ended or of(ercd(or sofe.Il,hownver,1he 6ulfding or � � � Improvement Is sold wifhln one year of complefion,thc � - ' � owner•6ullder will hove the 6urdon oiproving fhat he did ' nof build or Improvo for tfie purpose of scls.) �� I am exempt under Sec. , _ 8 8 P.C.for ihis reason Daie Owner