HomeMy WebLinkAbout1634A (9) . _.. _ _
_ __
� �
" WORKERS'COMPENSATIONDECLARATION �6A663 �a�e� APPLICATION FOR ELECTRICAL PERMIT �
I hereby aifirm Ihpt I have a certifimte of consenl fo self �E'� �
insure,or a cer�ifwte of Workers'Compensation Insuronce, . COUNTY OF LOS ANGELES BUILDING AND SAFETY
. or o cer�if�ied�co.�p�y,��her�e�of(Set.3800,La C.) �
O�y No!�pmpony FOR APPLICAM TO illl IN q�pp�55 1763 i ff
Cerlified copy is hereby furnished. EACH NO. FEE
New ResideNial Bldgs.8 Pools
� Cerlified m � I d 2-Fomil — �aA'��TY
py is filed wilh the coun�y building inspec- y,Sq.Ft. 5 — f �[[,��'
NEAREST
tion department. /'���� I Muhi-fomily Sq.FL �Rp55 57.
� Date 5 a` Applitont��Q'�'a `�'�"o�•�p Residenlial Swimming Pools . OWNER OR � �
p FIRM NAME
p CERTIfICATE OF EXEMPTION FROM WORKERS' Ovtlels:Rec�Light 3$w,� . 11 M�I� ,
i COMVENSATION INSURANCE First 20 � ADDREu 1�Q7S��I�'i4E
(rni.sa�io�n•.d no�b•compl•�•d u+h•wo.k In.olvd br Total No.�L
� fb�p�rmit b Fo�on�hundr�d dollan{f100)or I�sr.) " Additionol - CITY �Q� r�.. Tel.No
PIAN CHECK
�� I cerlify lhat in the performance of the work fo�wh�ch this - Appi��M
�, permit is issved,I sholl not employ any person in any monnar
so as to bemme subject to the Workars'Compensotioa Laws. lighting FixNres Firsl 20 � ADORES$
'� � � Toial No. 3 Addilional
CITY � Tel.No n i
Date opplitant Fixed Applionces Not Ovar 1 HP PERMIt
NOTICE TO APPLICANT: If, ofler making this Certi(imte of qppIICANT
Eaempfion, you shou�d becomp su6jetl �0 1he Workers' Range,Hearer_D.W._
Compenw+ion provisions of the lobor Coda;you musl forth- Oven �Dryer _W.M._ ADDRESS 7�ffi� �
, ifh comply 'Ih such provisions or Ihis permit sho�l be Tap _FAU —W.H.—
� deemed ravokad. � CITY Tel.N ,
� LICENSED CONTRACTORS DECLARATION Hood �Fan _Oiher_
� Disp. _Room Air Cond. — UCENSE OR , Class.
� I hereby affirm ihot I om licensed under provisions of Chopler 9 REG NUMBER'.
(commencing with Section 7000)of Division 3 of the Business pawer Apppratus 8 Lorge Applionces DISTRICT NO. PROCESSED BY ' Y
and Professions Code,and my license is in full face ond affecL . !� d
Size 8 Type HP,KW,KVA,or KVAR ' 0
License Number 4�5� Lia Class R � � . U
Up to 1 Ind. FINAL ��'�/
�Pro�nY,hi�m Over I to 101nt1. DATE E7 VALIOATION �
Contracfar — ote �11"'� p�er 10 fo 50 Ind. /� � � O
❑ FINAL
I am exempt vnder Sec. Over 50 ro 100 Inc. BY �, _ . 6
� B.BP.C.for this reason Over 100 �n
� ' Services,Swbd.,MCC 8 Panelboords , � Z �
� �O1e' 0-2W Amp.Under 600 V
i Signo�ure 2(11-1000 Amp.Under 6W V �
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint Elecl. ' �
�'� SINGLE fAMILY Temp.Power Pole 8 Appurfenances - �
I HOME OWNER-BUIIDER DECLARATION � ' � ' �f'� (�J.�R
�'�. I hereby affirm thot 1 am exempi from�he Controctor's litense S'9n wiih One Branch Circuit ,
law for the following reason(Section 7031.5,Business and Additionol$ign Bronch Circuits - . �� �� �y �C
�� Professtons Code): . ;
�� ❑ I,os owner of ihe r erl will do the work and ihe Misc.Conduils&Conductors - ', � �•-°2�.��
P� Y� Other See Com lete Fee Schedule_
� slructure is not intended or offerad for wle(Section . ( P ) � _ . -__ .� o �L 1.O��
� 7044,Business and Professions Code). '
CONSTRUCTION LENDING AGENCY � C S�D v—H�7
I hereby affirm Ihol there is a conthuction lending ogency ior ��,
. Ihe performance of Ihe work for which fhis parmi�is iswed PERMIT fEE - . (Sob-Total) �V �� �
(Se[.3097.Civ.C.). � ��
PLAN CHECKING FEE . . . .
' Lender's Name - �
I PERMIT ISSUING FEE �0 �
�' lender's Addrass � �
I certify that I have read this appiicotion ond store that the � TOTAI FEE o2� �0
obove informotion is mrrect.I agree ro comply with oll County I �� �
� inances and S�ate laws regulating Electrical wiring,and � . � I
h e6y aulhorize represeMotives of ihis Counly to enter upon � ��, � � -
I. �h obo�m ioned propeny for inspection purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
.. � �cc.a� �—�'—� � . ', . . . .
� ignalure of Permiltee Da1e � � �
�% •
. __ .
� ' ����� " . . OWNER-6UILDER DECLARATION
, � � - APPROVALS . -DATE � SIGNATURE � �.... . . . . �
TEMP.PO�YER POLE �� - � I here6y affirm ihat I am exempt from the.Contractor's
, - � - -�- .License law for ihe following�reaso� (Sectlon 7031.5.
, . UNDERSLAB WORK � � � Bu:7ness ond Pro(essions Code):Any city or counry wh�ch
ROUGH CONDUIT � � � � �, reqvlros a permlt to tonslruct,after,Improve,demoHsh, ��
� �or repalr any strucfure, prlor fo us �ssuance, also rr
. . � � WIRING �p��S . . , puUetfhaopplican}forsuchpermltfoflfeasfgnedsfate-
' � - � FIXTURES . . . _._ .. � mmf Ihat ha!s Ilcensedpursoanl to t6o prov8lons o/fhe
. � . Confractor's Ucense Law(Chapfer 9(commencing wlth
� POWER AUTHORIZED � - � - Seclfon 7000)ol DlvBfon 3 0!Ihe Buslness and Croles-
, , � _ � slons Codef or/fiat he Is exempt Iherelrom and fhe basis
� ' ' UTILITY CO.NOTIFIED � for the alleged exempfion. Any vlolatlon of Socflon '
� . �� �� � FINAL � �� GnEer on yronf ' . �7W 1.5 6y any oppllconf for a permlf sub�ecis ihe oppll-
_ conf fo a civil panalfy of nof morn fhan Nve fiundred
. -� � NOTES '� - - dollars(5500).:
, ,. . . - ' ' ❑I,as owner of ihe property will do the work,and
� � � - � � � 1ho structure Is noi Intended or offered for sale.
. � � - � � . . (Sec.704l,Banlness and Pro/esslons Codo:..The Confrac-
, � � ' for's License Law daos not appfy eo on owner of properry
� ,,_ , .,.. , . who bullds or Improvos thcreon, and who does such
- work Flmsclf provlded lhot such(mprovemenfs are nor
� �� � � . - - - - - . - Infended or oflered lor sale.If,however,fhe bullding or
� � Improvement Is aold wlfhin onv yeor of complefion,1he
. �- �owner-bu1lderwfHhavelFe6urdonofprovinglhafhod�d
� nof bulfd or lmprove for the purpasa ai sale.)
� � I am exempt�nder Sec. ,
B E P.C.for fhis reason
.. . � � .-. Dote �
Owner