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Home My WebLink About1415A _ _. ____—.._ _. L WORKERS'COMPENSA710N DECIARATION �� ,8, . pppLICATION FOR ELECTRICAL PERMIT � I hereby affirm thot I have a certifimle of cansent to self �E"� � insvre,or a cerfifcate of Workers'Compensation Insuronce, . COUNTY OF LOS ANGELES BUILDI�II"s AND SAF�Y or a ca7rfiiie cop h [e/p'(�Sec.3800,Lob.C.) atT 1�7�� Companyl�Q��I�p-�D FORAI►UCAMTOi1LLIN JOB Certified copy is hereby furniahed. New Residential Bldgs.8 Pools EACH NO. FEE A�E55 �i � Certifiad copy is filed with ihe couMy building inspec• 1&2-Family,$q,pf. ��x� S = E G ��A��TY lian departmeot. Muhi-fomily$q.Ft. �Rp;S ST. �T-�/G Dofea'��U� Applicant�rn-�'�-d��"'�n�� Rasiden1io15wimmingPools RRMENAME f CERTIFICATE OF EXEMPTION FROM WORKERS' � Outlets:Rac�light�_Sw.� � �'�� COMPENSATION�NSURANCE � � � ADDRE55 ` firsl 20 - {Thi��clion n��d mt 6�complN�d if�h�work involr�d 6y Te�a�Na J Additionol GITY � Tel.No.� d7 }h�p�rmi�h lor on�hundr�d dollon(SI00)or lus.) � � I certify thot in Ihe perTormonce of Ihe work for which Ihis . ' PLAN CHECK . APPlIC4M permit is issued,I shall not employ any parson in ony monner so os ro became su6ject to the Worke�s'Compensa�ion lows. L(9hiing Fixtures First 20 -ADDRESS � � � Total No. Additionol • 5 � CITY Tel.No. Date oppliconf Fizad Applianres Not Over 1 HP � PERMii NOTICE TO APPLICANT: If, aNar making this Certificate of APPLICANT � Exemprion, yo� should bemme�suhjeU ro�Ihe Warkers' Range_Heater_D.W._ . Compensation provisions o�1he Lo6or Code,you musl forth• Oven _Dryer _W.M._ ADDRE55 with tomply with such provislons or �his permit shall be Top_ —FAU —W.H.— . deemed revoked. � Nood _Fo� _Other_ CITY Tal.No. LICENSED CONiRACTORS DECIARATION . � IICENSE OR I heraby affirm thot I om litansed under provisions oi Chapler 9 Disp. _Room Afr Cond. — REG.NUMBER 7� Clou. - (commencing wilh$ecfion 7000)of Division 3 0l the Business power Apporatus 8 Large Appliontes DISTRICT NO. PROCESS D BY � and Professions Cals,and my licanse Is in full force and effecl. /Q O ��J $ize 8 Typa HP,KW,KVA,or KVAR ( license Number, �l Lic.Class� Up to 1 Ind. - F�NA� � - � �� V � �� .c� Overl to 101nc1. DATE � �J� VAIIDATION � Q CoNroclor��n P. oa�e � Over 10 to 50 Ind. FlNAL V ❑ I am eaempt under Sec. Over W to 100 Inc. BY � . . . d Over 100 H B.BP.C.for this reason � � ► 2 ' Da�e: Services,Swbd.,MCC 8 Panelboards -- � 0-200 Amp.Under 600 V Signature Z01-1000 Amp.UndeF 600 V � - - ❑ Ove�1000 Amp.or Over 600 V E.emption for Reg.Maint EIeU. ' SINGLE FAMIIY � Temp.Fower Pole 6 Appur�enonces t 1 4 1.5 A HOME OWNER-BUIIDER DECLARATION Sign wirh One Branch Circuit . I hereby affirm that 1 am exemp�from the Contracmr's license Addirionol Sign Bronch Circuils � �-� � � � �� Law for ihe following reason(Sed�on 7031.5, Bosiness ond � . Professions Code): I •-•9 2 4 4 . � Misc�.Condoi�s 8 ConduUors ' .- I,as owner of�he properry,will do�he work and the , . � � s struc�ure is not intended or offered for sale(Section O�her(Sae Complete Fee Schedule)_ . •9 2.4 4� . 7044,Business ond Professions Code). �•Z�7—B 4 CONSiRUQION LENDING AGENCY ' � � � � � - I heieby affirm�hai ihere is a construction lending oqenty ior � � 1he performance of the work for which this permit is issved � PERMIT FEE � (Sub-Totol) � {Sec.3097,Civ.C.). � � - � � fl'xYLT�R!'-.� P�'4N CHECKING FEE Lender's Name . I � )c h��l D�. (�A-• PERMIT ISSUING FEE . Lender's Address � 1 . � I ceriiiy ihat 1 hove reod thrs opplication ond state that fhe TOTAL FEE a,(` above informotion is correct.I agreB to mmply wilh oll County ordinances and 51ate lows reguloting EleUritol wiring,ond here6y aulhorize represenlalives of this County to eoler upon : � th e-mentioned property for inspeclion purposes. , SEE REVERSE FOR EXPLANATORV LANGUAGE Z—6-P'� igna�ore of Pe iitl Da+e _ APPROVALS � DATE- __ . . � . __ . � _ OWNER-BUILDER DECIARATION � � . SIGNATURE "" TEMP.POWER POLE � � - - . � hero6y affirm thot i am ezempt from ihe ConlraUor'S ' - - � , Licensa Law tor Iha following�roason (SecHon 7031.5, UNDERSIAB WORK � ' busfne5s artd Pro(esslons CodeJ:l�ny clry or county whlch � ROUGN CONDUIT 3 � roqul�es a permll lo construcf,alfer,Improve,demol�sh, or repalr ony structurc,prlor fo Bs iasuonco, alto re- WIRING a � qviresthaoppfirontforsvchpermlffallloastgneds�o�o- _ ' ment t6af he Is Itcensed pursvanf to fhe provis�ons o(f6v _ � FIXTURES ' - - Conlrotfor's Lftenso Law(Chapter 9(commenc(ng wNh "' � POLVER AUTHORIZED ' � Sectlon 7000)of Divlsfon 3 0l�he 8usiness and P�ofes- slons Codo)or that he(s oxempf fbere(rom and f6c basls UTIIIN CO.NOTIFIED . for fho allaged exemptlon. Any viofafion ol Sectlon --- -� FINAL � �nler on .t , � 7031.5 by any appbcant for a permR su6j^cts ihe eppll- �on( cent ta u eiyfJ penalfy ol nof more ffian(fvo hundred - - �- NOTES -- � - � � dollara(S500J.: � . ' ❑I,as owner of ihc property will do fhe work,and - - ihe struclure fs not inlended or offered for solo. • � �� . � ' (Sac.7041,Buelness and Pro/osslans Code: ihn Con�rac- � -� for's Llcense Law does nof opply lo an owner o!property , _ . � wba bol(ds or fmproves lhercon, and who does such work himaclf provldod that such improvomen�s nre not � � � � � - --� ' - � Intendod or offered for svle.If,however,1he bullding or 'Improvcment Is sold wlfhin one year of compfo0on,ihc , . _ . ownervbvifderwllfhcvefhoburdenofprovingthafhedid nol 6ufld or Improvc for Ihe purpose of salo.) � � I am cxempt undcr Sec. , __ B&P.C.for this reason �ate Owner