HomeMy WebLinkAbout1657A �
WORKERS'COMPENSATION DECLARATION CEA-806G �0/81 P1r P L�CA i IOiV �OR ELECTPICAL PEPMIT �
1 hereby aff7rm�hat 1 have a certificate of consent ta self
msure,or a cenifiwte of Worken'Compensa'on tnsurance, COUNTY OP LOS ANGElES ,/ `j./ BUILOING AND S�IFETY
or a rh aed opy thereof�Sec.3 ,La6.C ���
y ��.
IIIppp{{{''' �C/-r�-.r,a�—Compan FOR APRICANT TO fltl iN JOB ��)
,F'�i-�Ceriified copy is hereby furnishad. EACH NO. FEE ADDRESS EJ'�1C.Gi .
New Residential Bldgs.8 y h
/� Certified topy is filed with rhe coumy 6uilding inspeo- 1&2-Family,Sq.Ft. G� S — 5 r LOCALITY �}'' �T
tion daporfineM. Muhi-fpmily$q.Ft. N�Rp�SS/1j �""/d ��d�'�'(J L% ,/ //
TS.�•LLfFK.� �� �f
• Residential Swimming Pools OWNER DR p
Da1e Applicanf FIRM NAME -
CERTIFICATE OF EXEMPTION FROM WORKERS' Outleh:Rec�tighr Sw. I
COMPENSATiON INSURANCE � 'f"— �� � AD�RESS
(Thit secllon naed noi 6e compleisd N tha�werk invelved by First 20
Total No. Additional CI Tel.N�
ihe parmtl h for ona hundrod dollo�s(5100)or laat,) . plq CHECK
I cer�ify that in�he performance of ihe work for which ihis APai.tUNT
permit is issued,I sholl not employ ony person in any manner "
so as to become subiect to the Workers'Compe�satian laws. Lighting Fixtures Fi�st 20 ADDRESS
Totai No. Additionol
CITY Tei.No.
Date epplicant fixed Appliances Not Ove�1 HP pERnni
"'�TICE TO APPUCANT: If, ofler making this Certifimte of A��
mption, yo� should become subject to rhe Workers' Range_Heoter—D.W._
_�mpensafion provisions of the Lobor Code,yo�must forth- Oven _Dryer _W.M.-- ADDRESS �D
with comply with such provisions or thia permit shall be Top _FAU _W.H.—
daemed�evoked. � CI .No.
L�CENSEO CONTRACTORS DECiARAT10N � Hood _Fon _Othe�_ .
Disp. _Room Air Cond. — IICENSE OR .Closs
f here6y affirm that I am licensed under provisions of Ctwpter 9 REG.�NUMBER
(commenc�ng with Section 700D)of Division 3 of Ihe 8usiness power Apparotus&Large Appliances DISTRICT NO. PROCESSE BY r �
and Professions Cod , nd my license is in full force ond effect d
/(��/� Size 8 Type HP,KW,KVA,or KVAR rQ O
License Number Lic.Closs��« U
Up to I Incl. FINAL o
���7'f��lA,� Over 1 to IO lnd. DATE �! VAIIDATION �
ConvaU� - Daie Over 10 to 50 Ind. � �
❑ FiNAI
1 am exempf ur�der Sec. Over SO to 100 Inc. BY � tVu
8.&P.t.for this reoson Over 100 cai�
Se.vices,Swbd.,MCC 8 Ponelbonrds � Z •
Date: 0-200 Amp.Under 600 V ,
Signafure 201-1000 Amp.Unde�600 V �� 5 5.7 R
QOve�1000 Amp.or Over 600 V , .
Eaemption for Reg.Maint.Elect. #� � � � �L
SINGLE FAMILY Temp.Power Pola 8 Appur�enances
HOME OWNER-BUILDER DECLARATION Sign wi�h One 8ranth Circoii � � ��'�7 Q
keby affirm�ha�I am exempt from ihe Contrattor's License .
)for the following reason(Section 7031.5, Business and Additional Sign 8ranch Circuils � � a���C,x
Professions Code): -
� Misc.Conduits&Cond�ctors 0 2 2 7 -8 4
1,as owner of the property,will do�he work and the
structuro is not intended or offe�ed for saie (Section Other(See Complete Fee Schedule)_ �
7044,Business and Prvfeseions Code).
CONSTRUCTION LENDING AGENCV ,
I hereby affirm fhot�here is a consirucfion lend�ng ogency for
the perfo�mance of Ihe work for which fhis permil is issued PERMIT FEE �Sub-Total)
(Set.3097,Civ.C.).
. PLAN CHECKING FEE .
Lender's Nome �
PERMIT ISSUING FEE
Lender's Address
i certify Ihat I have read tfiis opplication and state that the TOTAL FEE �
above informati correc�.I agree to comply with all County
ordinances and St te I s regu�ating Electricai wir7ng,and ' �
i here authoriz tatives of this CouMy to emer upon .
h ov@-men d e .i specrion purposas. SEE REVERSE FOR EXPLANATORY LANGUAGE
��
I ;Si t e of Permin ._ Date �
�. . ; ;
. z � � v�- X g o .z m `
... 0 � � C � � C � �
. .. . m r =1 m C Z � m '
N (l D � � n "� U �
� 0 C. g :m � O
O � " � p 8 D
-� u. • �
R
' T m: � � m
v ��
�3
e
�
a
a �
:.
�-
�
Z
' D
C
70
m
I
I
� � W Q � �' � 3 � ° oNnm �� ��' ���C �� c� s ' ,
�w a m
lD � S O� 5 � � Q u' O � N W t � � O
'm �° cy C 7 °cn �S�n"� ��O ��o� �°, ?S�,c� N �<
n � `a�3a3 � � g�� wa� oa�o` � o '+ oa6o
0 3 ° o.' o � '" m wm �, o_a m °�N ev a W af � �
v - . m o -«o �c • o .. 5'c� ' o = �=`� „°03
�" c � F " m� F 3 3 � a b a S"'q n i�° T m
� N � O �O 0 � 3 a N � � m�m � O N (0 � C N S� I�
� � � s�'"'m O � � � -w C �1 � S� m M -..� � N m _ �7
, o cn o m E N aK � � ' S �' "" 3 `" � �v o � � N �3 �
� ,
'� M u
� " � � � � .�,.��m°s o o�.a �° ,°a � `"'A a �'a � °a�• K 7rno
'� ac ,_N m� m o 0 o c 3 Q,�'c t � a' �
' . � � � �.cc'o� N � �vbro v° � � ' c .. m3 �m
_ . � -� a`° �.3.0'�0� 3m � 3-� 3o y�v �
'.o `�� ° ' o � m'� 03`� �`D � o �-•�,'� o �.
.. .N �O � 3 � O N /0 f /D < m�O p N ti O O .�7
°.o °.m o '2� �o 0 0�Q o�o� �c� o Ns -D-�
� ' a o 3 N 3 o c o m -O
. 0 � 03-3 �'m o3- -..� � 0 3 � _ � ,'p � � `° Z
.s �. ' �rp v co � ° o s m`m < w � o �o � �p m c a n
o' a-.,m . m o a� � o � ' o-> > >
s� c �+ O b �a T T T 4 . y m � m
� K
, ;.j °-° N o ?. ir � c �m v`n a,ao o f wo -.
' � a tO � � � �O m� 'o'' ° '"F' zmm ?-^ i„�„ �
. am° ° �� a a -� H , T�c T'