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HomeMy WebLinkAbout0948A bVORKERS'COF.SoFpISAT10N�ECLARATION '���'� � � � � - - . ]BABG3 ,o-a��� qpp�ICATIOR��FC?R����ELECTRICAL�PERMrT �.� �.,,� ; , � I I hereby a`firm that I fi5ve a erhfcafe of co�sen(�[o�sel( nsure bE-So�sG or a certticam of vdorkers'c..mpensztlon�nsura.ic=;ot a certified COUNTY OF LOS ANGELE$ ��� � � �BUILD(NG�AND�SAFETY copy thereof(Sec.38GO.Lab.C.1 � � � Po'�.icy NO. Company '.� . FOR APPLICANT TO FILL IN�_ . JOB i /� ' �q . . . . ADDRESS� /� e ) �(,J�. f`j n ❑ Gertrfied conY s hereby f vn shed Neai Residen}iai Bldgs.&Pools ! EACH NO. FEE ❑ .�..�. . �.` . ,.;.: ,�.�.�_. .-.:-:.. .� . � LOCALITY_. . � Certfi.�d cooy is iiled nd'� the cou�ty 6ui:ding iospection 1&2-Family,Sq.FL 5 — S � , +*�ya $ � .NEAkES.p..... ... ................. .... department. Multi-fami!ySq.Ft. CP.oss.;[QG�7, L�N e3F� � 5N. ' �� Rr.sidential SvJimmin�PoolS - OWNER OR' � �r Da�e � A,Op�CLrII '� � FIRAANAME • . CERT FICATE OF EXEMPTION�KROM WORKERS �� � � � I mAi� � Dutlets:Rec—Light—S:.—� �,�- � COMPENSATIONWSURANCE � � , � � �� aD�aE55 Rry �(fhis section neetl not 6e�completed if ihe vuork involved by�the�' i � .., ,- � � Fi�st?_0�� CIT �� � Tel.No. d 'permi�is for`one huntlred dollars($706)�or less.)� � � 7otal No. Acdihonal� �p 6 7�[-� I certrfy,ha!�in tha�p�rfo�marice�oi�t!ie mork foi-wfiich��tli�is permit� � PLAN CHECK ,i/� 'is ISSUEd,I Shal�noi e:nplo 'any�pe.sor,In"any�mannef�so as�to APPUCAN? 7 tiecome subject to�the�VJcrkers'Campens"` � Lightina Fxtiires First 20 I �AD�RESS � (' o'.al No. Additiona'�. �-� �$'Da e A�plic . � I �� CITY ' .� �- � Tel.No.,..---•.-.+ � NOTICE TO��APPL CANT:� 1 afrer mak no !hi� Cer}i!i�te of Fixed Anpliances Not Ovcr�1 HP � pEqMiT � /' " ���-- � � '� � � �� � Exemption.'ycushe�d�ecomesublecf�toZheWorker5'Compensation - F7ange_ Nez?e�_ D.W. _ I .4PPCICANT (,.�� ^�' ^ ���Arovisons of�;hs Labor Code yuu mus;�forthwi[h�comp�ly�edith such ��' Oven — ��yer�_ VJ.M._ I R�DRE55 � � ��R j��� �� provisions_cr this permit shall be deemcd mvoked. - Top — rAU -_ IN.H._ I CITY .� �� Tel. o����� � ��� ��LICEN5ED�CONTRACTQRS DECLARATION �,� �� � Hood— Fan _ O;ner— �G• �I hern6y zffirro Mat I�em��5 ensetl��untlzr provisioris of�Chap;er 9 � uceNS Oa i Dlsp. — Room Air Cond. ._ Ciass. �(commencin�wth Section 7DC0)of Division 3 ot the�BUsines5 2ntl � � REG.�NLIMBER - Protessions�Code;and�ing Ilrerise-is�in�full force�and effect. � � � oisraiCr n:o. PROCeSSEo sv _ �Po�ver Apparatus&Large Appliances ,/ � Size&Type H?,KW,KVA.or KVAR / � � License Number Lic.Class� � Up io�Incl. I FINAL- V . - �ATE � �� p.7 Over 1 to t01ncL ✓- �"l...- � VALIDATION � Contractcr � ' �ate � � � Over 10 to 50 Incl. � U I—I FINAL L! I zm exemF�und�r Sec �! Over 50 to 100 Ina �1r �� � B.&P.C.for this rezsan - � Over 10C gY +�T� y �f . Date: - - � ;Services,Sw6d..MGG&PAnel6oards � � � . � . . . C-2C0 Amp.Under 600 V Signature 201-1C00 Amp.Under 600 V � � � �� � � �� � � ������� - ������- � -- � Over 1000 Amp.or Over 6C0 V Exemption for Req."A2int.Elect. � - � -- �. SINGLE FAMILV �� �� � �Temp.Power Pole d Appurtenanr,es HOME 01NNER-BUILDER CEC�ARATION� � . Sign witn�One Branch Circuit <Q r/�1,f5 r� � I hereby 2ffirm th2t I 2m exempt frotn�fhe Coniractor's license tav� pdditionai Sign Branch Gircuits for tne following reason(Section 7031�.5�.Business and Protessions ._ . r, @ A � � �G ! Code):. .. ��� .I . �j �as owner of the prcperYy,vuill Co tne v✓ork antl the shucture E �isc.Conduits&Conductors . -I ° °' i C.��.�J � /\. is not Intznded or ofFered for sale iSection-7044�.Business�� �,,Other�(See Complete Fee Scnedule)_ ar�d P�ofessions Code).� � �� - � � � � � � � ' �� I j,r 5 F =:�..Ba 6 t: � .._ , - CONSTRUCTION I.ENDING AGCNCY . �„�. �_ �,-,� , �d; 7-g g I hereby affirm that tfieie��is�a constructio�lendino agency�-fb?the performance of the�,work icr ia�hich"tFis oermit is��issued(Sea 3087, �� PERMIT FEE (Sub-7otal)� Civ:C.). . . .. . . � PLAN CHECKI�G FEE Lender's Name � � � - - � � � �� . � PERMIT ISSUING FEE � Lenders Address � � � I certify that I have�ead this 2opiicztion antl�sfate that the above � TOTAL FEE information is coirect.I agree to comFly with zll County rordinances � � �and 5[ate laws�regWatinc E!ec}rica! wiring, and hereby autherize � �� �� � -�- '�- � � ' . � repYesent2tives of this�County fo-enter upon tfie abo�ie-mentioned � � �� � �" � �� � - � � �� � ���� �_�� � �� � .. . �. . . . properry for inspection purposes. � � � . . - ' . �,,, ... :. . ... . . . 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