HomeMy WebLinkAbout1416A (7) .WORNERS'COMPENSATIONOECLARATION � 76a66� ,0,8, qpp��CATION FOR ELECTRICAL PERMIT .�
I here6y affirm thot I have o certificate oi consent to seff C6806� .
insure,ar o certiticaie of Workers'Compensation Insurance, COUNTY OF LOS ANGELES� BUILD�NG AND SAFETY
or a cer��fied copy fhereof(Sec.3800,La6.C.)
POol�icy No. Compony FOR A►►UCANT TO iRl IN �� r
Certified copy is hereby f�rnished. New Residenlial Bldgs.8 Paols EACH NO. FEE A�DRESS .� L ,/ C �E/� �
� 1 8 2-Famil IOCALIT /�� L
CeNiifed copy is filed wilh the couNy building inspeo Y.Sq.F�. E — s lAV IK N IhM��/p
�tion department. ' . Multi-lamily Sq.FI. — NEARE57
Residentio�Swimming Pools CRO55 S7 /�/S
Date Applicant OwNER
. - rx�.n,d� /f L L/fie.rj
CERTIPICATE OF EXEMPiION FROM WORKERS' p�lleis:Rec—Lighr_$w._ M'A�� r
COMPENSA110N INSURANCE � A��RE55 Gy I}"� COU.�-'r
� tThia t�dien nNd not b�eom 1�»d�f th�work Inrolv�d b First 20
h�p�rmit is for on�hundnd dollars(SI00)or bss.) Y Total No. Additional CITY -� Tel.No.�fj�-2-3
I certif lhat in ihe erformance oi ihe work for which this � � P�AN�HKK p� l�� �'
Y P APPLICANT !�r L E V ri�y O
permii is issued,I shall not employ any person in any manner
so as io become subject io the Workers'C mpensation Laws. Lighiing Fiztures Firsi 20 ADDRESS�f/,)`r �� L CO�`1/.v6" S'�
Tolal No. Addifionol
� Date Applicant ❑TY /f/(Jr� Tal.No�,s�}=s�'
NOTICE T APPLICANT: If, aNer making this Certificate of Fixed Applionces Not Over 1 HP A�����,qN7
Exemption, yoo should become subjec� to ihe Workers' Range_Hea�er_D.W._ .
Compensation provisions of the lobor Code,you musf forth- O�en _Dryer —W.M._ ADDRE55 �f� ��v�'
with comply wifh such p�ovisions or ihis permit sholl be Top _FAU —W.H.—
deemed revoked. Hood _Fon _Other_ - CITY s',�_ , Tel.No.
� UCENSED CONTRACTORS DECLARATION - uCeNse Oa
I hereby affirm fhot I om licensed under provisions of Chapter 9 �Disp. _Room Air Cond _ REG.NUMBER� 7� Clasa.�,
(commencing with Saction 7000)of Division 3 of Ihe Business DISTRICT NO. PROCESSED BY
and ProfassionsCode,and my license is in full iorte and effe:l. ?i�+'er ApparaNs 8 Large Appliances . , / Q y�
Sixe 8 Type HP,KW,KVA,or KVAR - �
license Numbar �2'��� Lic.Class�_ Up to 1 Ind. fINAI . . . U
Contract -� �—�������are___7/f� Over 1 to 70 Incl. DATE �J � �i� VALIDATtON 0
Over 10 ro 50 Ind. FINAL / V
I om exempl under Sec. Over 50 10 100 Inc. BY W�
B,BP.C.for�his reason Over 100 'n
�j'� Services,Swbd.,MCC 8 Panelboards � � a � - ?
_ Date: � 0-400 Am Under 600 V
Signr+n�rP / 201-1000 Amp.Under 600 V � . . - . s 1.4 1,b A
❑ Over 1000 Amp.or Over 600 V � tS• • • • •'�
Exemplion for Reg.Maint.Elect.
SINGLE FAMRY Temp.Power Pole 8 Appurtenances� ,� � �2�5� �
HOME OWNER-BUILDER DECIARATION Sign with One Branch Circuit ,• • •2 ra rJ Q�
I hereby affirm that I am exempt from�he Contractor's license Additional Sign Bronch Circui�s � �
law for the followinq reason(Sec�ion 7031.5, Bus�ness ond . Q 7,� E�fi 5
Professions Gode): �
❑ .I,as owner of�he property,will do the work and the M;sc.Conduits 8 Conduclors � -
strotfure is no1 intended or oftered fo�sale(Seclion Other(See Camplete Fee Schedule)_ '
7044,Business and Professions Code).
CONSTRUCiION LENDING AGENCY -� - .
I hereby affirm thot Ihere is a construcfion�ending aqency for � � .
ihe performance of ihe work ior which�his permit is issoed PERMIT FEE � � - � (Sub-To�ol) .
($ec.3097,Civ.C.).
. PLAN CHECKING FEE - � . � .
Lender's Name
' � PERMIT ISSUING FEE . V � �
Lender's Address . �
, I certify Ihat I have read Ihis applitpFon and stole thot ihe TOTAL FEE
above informo�ion is correct.I oqree�a mmply with all Couniy � �
ordinances and State laws�egulating Eletirical wiring,ond
hereby ourhorize represe �ives of this County to enter upon � � - A_� � d - �
the above-men' n pr er�y for inspec�io r oses. SEE REVERSE FOR EXPIANATORY LANGUAGE �""�� L� �"`'� �""'r
• d'''��
Signature of Perminee Dat �
' APPROVAIS DATE �� � OWNER-BUILDER DECLARATION
. SIGNATURE �
- - � . TEMP.POV✓ER POl£ I hcroby affirm that I om�,xempt from tho Contrac�or's
. Litense Law for Ihc following roason (Socfion 70J1.5,
UNDERSLAB WORK . Bus Iness ond Professfons Code):Any dfy or county whlth
ROUGH CONDUIT req�Irvz a pormlt to construct,a7fer,�mprove,demof�sfi,
. � , � � or ropotr any structurc,pr(or to Its Iss�anco, also re-
WIRING , qulres f6e applfcant forsuch permlt fo Itle a sle�ned sfo�e-
� FIXTURES � menl lhat ha ls Ilcensedpursuant�a fho prov7�lons o1 fhe
, . Confracfori llcanso Law(Chapler 9(commencfng wllh
- � POWER AUTHORIZED � � � Secflon 7000)af Dlvlslon 3 01 Ihe 6osiness and Pro(es-
� . slonz Code)or that ho Is exempt fherefrom ond Ihe basis
- � � U7ILITY CO.NOTIFIED for fhe alleged oxempBon. Any vlolalfon oi Sec��on
� FINAL . c7 70JL5 by any oppllmnt for o pvrmR subjects iho oppli-
... �rtter on...ironf � ranf fo a clvil ponafty af nol more fhon fWe hundrod
- NOTES � . � dollars(5500J.: . �
, �1,as ownar of 1he property will do the work,and
� � tho stroclure is not intended o�offered for sale. .
.� � ' � � - - (Soc.704�,Businoss andProfoselons Code: Tho Conirar
� tor's Llcense Law does not opply fo an owner of property
- . . ' � � � who 6u�fds or lmproves fhereon, ond who doos such
� work hlmself provided fhaf such Improvemenfs ore nol
- � - � � � � � Inlendedorolloredlarsale.lf,however,thobotldingor
Improvemont Is sold wi�hln onc ycar of completlon,�he
, . _ �o owner•6uflderwtll havo fho burden o/proving tha!he did
"- � - not 6ulld or Improvc lar t6e purposo oF sefo.J
� - I am exempt vnder Sec. ,
B&P.C.for}his reason
Date
, � � . � � Owner