HomeMy WebLinkAbout1604A (9) t-,.
WORKERS'COMPENSATION DEClARATION �6A663 ,o�a, qpp��CAT10N FOR ELECTRICAL PERMIT �
I�F.ereoy!;ffirm tho�I hove a cerliticale of mnsent to sell CE-BOtG
insure,or a certifica�e of Workers'Compensm�on I ronce� COUNTY OF LOS ANGEIES BUILDING AND SAFETY
or o certifi��y[d copy ihereof(Sec.3800,Lob.C.) _ .
�'�V❑olicy No- `��"��_Company $ FOR AP►LIUM TO Fllt IN !OH '
Ce�tified copy is hereby iurnished. New Residential Bldgs.8 Pools EA[H NO. FEE ADORE55 �7 �f Of. T L � C!T S �-�V,r
� Cenified mpy is filed wiih Ihe touny building inspea y. q. LOCALITY _
1 8 2-Fomil S ft. E — = YH�'�' q f'•
- tion departme t. Mul1i-fomily Sq.F7. — NEaRE57
^-7 _t6 �' i/�� Residential$wimming Pools CRO55 57. • 'f 5' f�•
Dale ^� Appliconl � OWNER OR
FIRM NAME 1� ( G�G(.{
CERTIFICATE Of E%EMPTION FROM WORK � � L hV.i�
� COMPENSATION INSURANCE Outlets:Rec LigM_Sw. . qooaeSS C� /=-r -C
iThis aMion n��d nol bo com I�f�d if 1M work involv�d 6 /n First 20 S
h•p�.mH ts lor on�hundr.d dolfa.s(SI00)or bss.) Y 7otal No. `� � Addiiianal CITY �yy a r� �.,Tei.No. `/ OGs'
I ceriify that in�he performonce of rhe work For which�his p�ppNCqNTK �
permil is issued.I sholl not employ any person in any monncr
so os to become subjec��o Ihe Workers;Compensalion Laws. Lighting Fixlures� Firsl 20 7 AD�RESS
Totol No. Addiiional
CITY Tel.No:
� Dale �4Pp���a�� Ficed Appliances Not Over 1 HP FERMIi '
NOTICE TO APPIICANT: If, after�making Ihis Ceiiificate of qppll�A,NT Ol« LI !G S�
Exemption, you should become su6ject to the Workers' Ranqe_Healer_D.W._
Compensation provisions of the Lobor Code,you must forih- Oven _Dryer _.W.M._ A�DRE55 � S a G?�,� r'yh ���L
with comply with Such provisions or this permit ahell 6e � Top _FAU —W.H.—
� deemed revoked. . Hood _Fan _Other_ CITY �' l`�;. Tel.No. S/{ C�]
LICENSED CONTRACTORS DECLARATION IICEtiSE OR � I
I hereby affirm ihat I om licensed under provisions of Chopter 9 Disp. ._Room Air Cond. — REG.NUMBER Q S' Cfoss. (
(tammencing with Sedion 7000)of Division 3 af ihe Business DISTRICT NO. � PROCESSEb BY
� and Professions Gode,and my license is in full forte and efiecL Power Apperafus&Lorge Appliances T �
/'� p Size 8 Type FiP,KW,KVA,or KVAR V
license Number_/ �� 7��Lic.Class� - � - � O
Up to 1 Incl. FINAL V
/ p � Over 1 to 10 Incl. DATE VALIDATION �
Conlractorl�LS��"' Gf��SDafe 7^ z � -y) ���� � 0
❑ /" Over 10 to 5D Ind. F� � �-
I om eaemp�under Sec. O�er 5010 1p0 Inc. BY 6
B.&P.C.for this reoson Over 100 �n
Services,Sw6d.,MCC&Panelboards ► � z
Da�e: 0-Z()0 Amp.Under 600 V '
Signafure 201-1000 Amp.Under 600 V �
' O . Over 1000 Amp.or Over 600 V i
.Exemption ior Reg.Moint.Elecl. �
SINGLE FAMILY Temp.Power Pole&Appurtenpnces �� 6 Q.4 A
� HOME OWNER.BUIIDER DECLARATION Sign with One Bronch Circuit ��. • o e e 2
I here6y affirm thm I am eKempt from the Contradvr's license Addltional Sign Bronch Circuits � �
Law for ihe following reason(Section 7031.5,Business and J a •y 0..�5 .
Professions Code):
❑ I,as owner of the ro ert M�sc.Condui�s 8 ConduUors o o - z .
p p y,will do 1he work ond�he •J Q 7 5 c�
struc�ure is not intended or oHered for sole(Section Other(See Complele Fee Schedute�_ '
7044,Business and Professions Code). , 0 7,2 J-8.rJ'
CONSTRUC710N LENDING AGENCY � - . �
I hereby oifirm thot there is a construdion lending ogenty for
the performonce of the wark for which this permit is issued � PERMIT FEE - (Sub-Total) ,� . .
(Set.3097,Civ.C.).
PLAN CHECKWG FEE � �' . .
lender's Nome
PERMIT ISSUING FEE Q _
lender's Address '
1 cerfify+ho�1 ha�e read+hh applicafion and sro�e Ihot the T�TAL FEE 3.(�„ ,
obove informa�ion is corretl.I ogree lo comply with oll County �
ordinonces end State laws regulating Electrical wiring,and
hereby authorize representatives o!this Caunly to emer upon � � � � � � -
the ab m lioned pr rty ion purposes.
SEE REVERSE FOR EXPIANATORY LANGUAGE
7-z3-SS
qnature of Permi�t Date ,
�.
- ' � OWNER-BUILbER DECLARATIOU� . . �
, � � APPROVALS DAif SIGNATURE
� � � TEMP.POWER POLE . I here6y offirm tha�I am exompt irom the CoNracror'z
�� � . Licrnso low for ih� follawing reoson{SeUlon 70JL5,
. . . UNDERSLABWORK . BuslnezsondProlesstonsCode):Anyo�ryormumywhlch
� �' requfres a pe�mif!o tonsfrud,aller,Jmprovc,demolish,
� ROUGH CANDUIT � � �
� or repo�r ony sfruNur0.prior fo ffs Issuance, clso re-
WIRING 11 ' . �� qWrosfheappllconNorauchperm�tfohleastgnedstote�
� -- FIMURES - �� . men!thot he fs 1(tansed pursuant to the provislons of fhe
- , _ � Corthador's Llcensv Law(Choplcr 9(commenring wilh
� - � POWER AUTHORIZED ��—6[�� �-=�� Sec/fon 7000)o/DiJlslon 3 0�fho 8uslness and P�oles-
. ���" slons Code)or Ihaf he Is exempf fheral�om and Ihe bazls
� � - UTILIN CO.NOTIFIED � �or �ho olfeged exempnon. Any vlo/atlon ol Sec�ron
- �� FINAI P c7 7031.5 by ony,opplhanl!or a permtt subjecrs fhe appll-
Gnler on_tront j cant to a dvil penaRy oi no�moro�han li�e hundred
� NOTES � _ dallars(ESDOJ.: . �
� � .• . . ❑1,os owner of tho proporty will do the work,ond
— --- - � � . fhe structure fs not Intended or offered for sale.
, . . . � � . (Soc70lS,Bus7nessandPro�assfonsCodrr ThcConlroo-
� - tor's L7canse Law does nof oppiy fo an owner o�property
� � _ _ � , � � wFo burld:ar lmp�oves thereon, and who does such
- � work himsclf provtdnd�fhaf such�mprovemen�s are no�
, - � � �. � fnfended oroHwad lorsola 1L however,tbe bullding or
- � Improvemenf Is sold wflhln one year o7 complo�7on,Ihe�
� _. � , owner-bullder w11/hcve eRe burden o1 provMp t6at he dld
� - �not build or Improvc/or thc purposc of sale,)
� I am exempf under Sec. ,
B&P.C.for lhis reoson �
IDale
Owner