HomeMy WebLinkAbout1592A (9)WORKERS' COMPENSATION DECLARATION
I .hereby affirm that I have a certificate of consent to_self
insure, or a certificate of Workers' Compensation Insurance,
or a certified ycy�P�y tthhe�re�of (Sec. 3 ab. •Cn.,),,
Policy No.1GLlR�Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec.
tion deportment.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This section need not be completed If the work Involved by
the permit Is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
sa as to become subject to the Workers' Compensation Laws,
Dote Applicant
NOTICETO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Cade, and my license is in full force and effect.
License Number \ N (SL`_7 Lic. Class IL
Contractor Date
❑ I am exempt under Sec.
B.8P.C. for this reason
Date:
Signature
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's license
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work andthe
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issuetl
(Sec. 3097, Civ. C.).�.IRIFT
e
Lender's Name k� l I X11 vv' t�
Lender's Address2O7 �' 1"Aq 5S
I certify that I have read this application and state Not they
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
ereby authorize representatives of this County to enter upon
bove-mentioned prooerly for inspection purposes.
i
Signa ure of Permittee I Date
,D.B,
PERMIT
CE-Be6(' APPLICATION FOR ELECTRICAL
CE.006
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN.
108
ADDRESS
New Residential Bldgs. 8 Pools EACH NO. FEE
1 & 2-Famil Ft. 5 — E
q...
LOCALITY
MulY o_ —
NEAREST
-
Residential SwimFt.
Residenlial Swimming Pools
CROSS ST.�
OWNER OR
FIRM NAME V,.
Outlets: Rec_Lighl_Sw._
MAILC p
First 20
Total No. Additional
- ADDRESS J C+
CITYAA T.I. o"jIi
Lighting Fixtures First 20
Total No. Additional
Fixed Appliances Not Over 1 HP
Range_ Heater_ D.W. _
Oven —Dryer — W.M. —
Top _ FAU — W.H.
Hood _ Fan _ Other_
Disp. Room Air Cond. —
Power Apparatus & large Appliances -
Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over I to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Ponelboards
0 • 200 Amp. Under 600 V
201 - 1 DOD Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole 8 Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits 8 Conductors
Other (See Complete Fee Schedule)_
PERMIT FEE (Sub-Tatal)
PLAN CHECKING FEE
PERMIT ISSUING FEE 6
,TOTAL FEE G
SEE REVERSE FOR EXPLANATORY LANGUAGE
ADDRESS
CITY Tel. No.
PERMIT ll ff
APPLICANT i -LL I rQ
CITY I Tel. No. D?
LICENSE OR �j
F�REG NUMBER ,J� 1� CIa55.
L DISTRICT NO. I PROCESUP BY
DATEv S I 3.
n VALIDATION
FINAL f
BY
;159.2A
#.....2
1••255.50
• .25,50=.
07,22-85
01
Y
O
V
ce
O
V
W
Z
APPROVALS DATE SIGNATURE
TEMP. POWER POLE
UNDERSLAB WORKS 3 77 �/�, bt[j
ROUGH CONDUIT
WIRING
FIXTURES
POWER AUTHORIZED
UTILITY CO. NOTIFIED
FINAL &I" on 5—
NOTES dollars ($500).:
[3 1, 1, as owner of the property will do the work, and
the structure Is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor's License Law does not apply to on owner of property
who builds or Improves thereon, and who does such
work hfmself provided that such Improvements are not
- Intended or offered for sale. If, however, the building or
Improvemont Is sold within one year of completion, the I
owner -builder will have the burden ofproving that he did
not build or improve for the purpose of safe.)
I am exempt under Sec.
B 8 P.C. for this reason
Date
Owner
V YYIV[K-tl VILUCK VGL-WKHIIVIV
I hereby affirm that I oll exempt from the Cont
_
licenses law for the following reason (Section 7031. 70JL5,
Business and Professions Code): Any city or county which
- I
requires a permit to construct, after, improve. demolish.
or repair any structure, prior to its Issuance, also re-
quires the opplicanf for such permit to file a signodstate.
ment that he is licansedpursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business end Profes-
sions Code) or that he is exempt therefrom and the basis
for the alleged exomptfon. Any violation of Section
7031.5 by any opplicant for a permit subjects the appli.
- -
cant to a civil penalty of not more than five hundred