HomeMy WebLinkAbout0899A (4) r— �'.�-'___»_.. _.».- ._.v�..� . _. .. . . . ' _ . : - -�-;
WORKERS'COMPENSATION UECLARATION - 76A663 �o�a� APPLICATION FOR ELECTRtCAI PERMIT � �
I hereby affi�m ihat I have a certifkate of consent to self �-� �
insure,or o certifcare of Workeri Compensation Insuronce, � COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
or ia,ceHifiP.�copy thereof(Sec.3800,Lob.C.J � �
� P❑olF.y No. Compony FOR AALKANT TO fRL IN ��b � - ��,i5�n'ryy L�1 ��
Cerlified copy is he�eby furnished. New Residential Bldgs.8 Poo�s EACH NO. FEE ADDREu
� Certified copy is liled with�he tounty b�ilding inspe:- 1 8 2-Family,Sq.F�. S = 5 LOCALITY �(�yy���D
tion deparimeM. � . Multi-tami�y Sq.R. CRO55 Si. N1 �y{Ct � ��
� Da�e Applimnt Residential Swimming Pools �aM NMnE
12.i t�uf� tic..lti�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outleh:Rec_Light_Sw._ �'��
� � COMPENSATION INSURANCE � � n�ORE55
First 20
(Thls a�t�be n��d no1 6a complN�d fi fh�woAi involv�d by Totol No. Additional GTY .. _ Tel.No. ( - � Cr�3
-, th�p�rmif I�for on�b�ndnd dol�nn(SI00)er b».)
PLAN CHECK .
I certify�hat in Ihe performonce he work for whic tftis APPLICAM �
permit is issued,I sholl nof emp y a per m y e �
so os to bemme subjec�to th ork rs' pe o n aws. ligMing Fiztures First 20. ADDRESS �
� � � To1al No. Additional CITY Tel.No.
� �afe`��Appli nf ixed Appliances Nol Over 1 HP pERMIT
NOTICE TO APPLICANT: If, r moking Ihis Cer�ifi te of AVPtIfANT � �
Exemption, you should become s�bject to th orkers' Range_Heater_O.W._
Compenwtion provisions of the Lobor Code,you must forlh- Oven _Dryer —W.M.— ADDRE55, � b �
wiih comply wi�h such provisions or ihis permit shall be Top _FAU —W.H.—
deemed revoked. - , ❑TY Tel.No. j {� �3
Hood _Fan _Diher—
- ' - L�CENSED CONTRACTORS DECLARATION LICEN OR
I hereby affirm ihat 1 am licensed onder provisions of Chopter 9 Disp. _Room Air Cond. — REG,NUMBER � Clau. _
(commencing with Section 7000)of�ivision 3 of ihe Business power Apparotus 8 large Appliantes DISTRICT NO. PROCESSED BY �
and Profesvons Code,and my license is in iull force and eHecr. - 1 6
Size 8 Type HP,KW,KVA,or KVAR i O Q
� License Number Lia Class Up�o I IncL FINAI V
� _ Over 1 ta 101nd. DATE � VAtIDATION �
Contracror �o�e O�er 10 to 50 Ind. FINAL V
, ❑ I am eaempt under_Sec. . Over 50 fo 100 Inc. BY . �
� B.BP.C.for this reason �°���� Z
. DO1e_ Services,Swbd.,MCC 8 Ponelboards . . G� ya�
. 0-200 Amp.Under 600 V /
- Signature 201•1000 Amp.Under 600 V /�/Y'yJ� ,/„1
❑ � Over 1000 Amp,or 6ver 60p V ^�-������
Ezemplion for Reg.MainL EIecL �� F�
SINGLE FAMILY " Temp.Power Pole&Apportenances . . . , .
HOME OWNER-BUIIDER�ECIARATION Sign with One Branth Circuit
' I here6y affirm Ihol I om exempt from Ihe Controctor's License qdditionol Sign Bronch Circuits -
Law for the following reoson(SeUion 7031.5, Bus�ness and � - �Q$Q 9 A
�' Professions Code): -
� ❑ I,as owner of 1he ro ert Misc.Condui�s 8 Conduclors� � ��+ •'�• •�
p p y,will do 1he work and ihe Olher See Com lefe Fee Schedule ,
. sirucrure is not iMended or offered for sale (Saction . ( P . �— � ^ •2 ra Jr�
' 7044,Business ond Professions Code). .
CONSTRUCTION LENDING AGENCY � � ° •P S.Fi O u
I hereby affirm fho�there is a construcfion lending agency for � •
the performance of the work for which this permit is issued PERMIT FEE � (Sub-Toial) D.6.21 -.8 5
'. (Sec.3097,Civ.C.). - '
� PLAN CHECK�NG FEE � . .
lender's Nome
PERMIT ISSUING fEE . - , . . . . . . ,
�ender's Address � '
' I certify 1ho�I hove reod fhis application ond smre thoi the TOTAL FEE as',s
ve informotion is cor ect.I o e to comply with all County
r inonces and Sta1 a s r �I ting Electriml wiring,and
h eby a tho�' re res 1 rves f ihls County ta enter upon � � � � � - - � �
t -m fio d pr rty f inspeciio purpo es. �
� SEE REVERSE POR EXPLANATORY IANGUAGE . . ..
2t
Signalure of Perm�nee Da�e -
-- _ _ - - - -_ -- - �
� .. .. � . APPR Vn� DATE � . OWNER-BUIL�ER DECLARATION f
.� � SIGNATt1RE � �
- ' . TEMP..POWERQOLE I horo6y affirm ihat I am exempl fram 1ho Contractor's '
. � ' � � License Law for iho following reason (Sec�lon 7031.5, �
, . � , �UN�ERSLABWORK BusinessondProfessfonsCode):AnyclryorrouMywhlch �
req✓Iros a permlf fo consfruct,alter,Improve,domolish �
ROUGN CONDWT ,
' � � ._. ... . or ropalr any struc}wc,prlor}p 1fs issuance, also re-
WIRING qulresfheopplkaM/orsuchpermitfofl7oas�gnedslato- �
FIXTURES monf fha}hals f(censedpursuanf}o fho provlslons of 1he �
- . _. � Confradors Lltenso Law(C6apter 9(commen[!ng wHb
� ' �- �� �� POWER AUTHORIZED � Secffon 7000)o/Olvlsion 3 01 tfie Buslness ond Profes- �
slons Code)or fhal hv!s exempt thorelrom and the basls '
� UTILITY CO.NOTIFIED � for,fhe allegvd exemptfon. Any violallon of SecNon
- � FINAL n �7031,5 6y any appflcant�for a permtt su6�ocfs Iho opplt-
, C.nf¢r on �ronl tonf to e eivll pena(!y of�not moro'than/ive Fvndred
� NOTES . - � dol7ars(5500).d '- ` %'�. i�� �_`, .
. _ , ; � � ❑I,as owncr of iha property will do the�vloik,and ,
' � ���� fho struclure is nat inlendad or affered for sala. � '
, � . .. 7 . , .. � _ . , � � (Sec.70d1,8uslnen and Proless7ons Code: 7he Conlrvo
� � for's Llcense Law does nof apply to an owner of properly
'��� � ' • - . . � � �� �� , _ � who bvlfds or Improves IBoreon, ood who does such !
work hfmseH provlded ihaf suth Improvemenfs are nol �
' Infondadorof(erod(ortafo.If,howevcr,fhebWldingor I
� improvemant�Is sofd witfifn one yeor af completlon,thc
- , . owner6uildorwllf have tho burden ol proving�Bat he did
' - ' � nof build or tmprove/or Ihe purpose of aale.J
I am exempt under Sec. ,
B&P.C.for this reason
�ate
Owner
_ ' .. . , '� . . ; - �, ... .��