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HomeMy WebLinkAbout1525A _..-----•-- ���.�...�..�.;� •� ..�����'°�-.� .... . . `���- — _ ,; . -. ,. . �. - , _...�.„t,x,;M _.W,.. .,_ _ . . _ : _..a..: � . . vVCRKERS COMPENSATION DECLARATION �.�� ea9s3 i�o at �' � � � � ��� � � � "�- . , . ..., . . � . � � �=�ofiu APPLICATION FOR ELECTRICAL PERIVfIT �'j � I here6y affirm thai I have a certificate e"r corsent to.seif i�sure or a�certificate of�Workers bompensafionlnsu�ance cr a certrfied �� -"- �� COUIdTY OF LOS ANGELES BUILDING AND SAFETY L� copy ereo.l ec. . a. . � � � � � � . � �. ......... .... . ... _...,.<._, ... . ... .....,.... . . ,....:. ::.. . , .,. � . .: ._._... .. ,_ -.. POIiCy No COmpanJ � � FOR�APPLICANT TO FILL IN. JOB '' " ;� ,r . ...... ........ � . . . . . ADDRESS � . ❑ _Cernfied copy is here6y fumished. Nevi Resitlert�al B!dgs.&Pools EACH NO. FEE � �:..:�..� .�..� ' . i&2-Family,Sq.F[ S — 5 LOCALITY . Certifietl copy�is�iiled vaith the county buildinfl inspection � department. . �ulii-Family Sq.�t. — -NEAREST CP�SS.ST. Date Applicant � ��� Residential imming Pools OYJNER OR�j� � FJRtJ�NAME.R - 7i ,� I CERTIFICATE OF EXEMFT!ON FROM WORKERS' � rdAi� COMPENSATIbN�iNSURANCE Outlets:Rec Light—Sw.— qDORESS � � This section neetl not�be com leted,'ifthe woric i�vqlyetl by.the Firs 20 �� ( P Total No._�_ AtlCitional V�TV Tel.No. permit is for orte hundred dollars(S100)or less.) �. I Certiiy that in the pefiormanCe of th2 vrork.for which this pefmit PLAN CHECK APPLICANT . is issued,I shall.not employ any perSon in any.mannsr,so as to . become subject to the Workers'Compensation Lavas. Llghtin�Fix.ures First 20 ADDRESS . � - - � � � � Additional � � � ' Total No. GITY Tel.No. Date Apphcan Fxed Appliances Not Over t HP � NOTIC TO A�T If fter m� his eitrficate of acRMii ✓ •.�'-- � EXemption you shoulG become subJect to the Workers Compensation Rang?_ Heater_ D.W. _ � APPLIGANT � � / � �/ � • orovisions of the Labor Gode,you.must forthNnth compry wi}h such Oven_ Oryer_ Vl.M._ � I AO�RESS � ��� provisions or tnis permit shall oe deemed revcked. Top _ FAU _ 1V.H._ CITY ��. Tel.No. � � � LICENSED CONTFIACTORS DECLARATION Hootl_ Fan _ Cther_ / � I hereby affirm.th2t I am licensed under provisions�of Cliapter 9 � �ICENSE OR ��. Icommencing rvith.Section 7000)of Division 3 of the Business and DiSp. —R0001 AI:COOtl. �. REG.NUMBER �A "-G7, . �'aas��"`/� �� ProFe35ions Code,and my IlCense is.in fUll fafCE 8nd effeCt. �ISTFICT NO. PROCESSEO BY Pov2r Apparatus&Large Appliances I - I � � � t�. C�` Q. Pa 4` ],.^�/}t /'+��� �� Sizc d Type HP,KW,KIA.or KVAR � �Pu..�. LiCense Number n /FJ" 7 ,�Lic,Class�L= Up tC 1 InCI. I FINAL � �� ���'�'� � �� U 'JJ !}�� Ove'7 to t0lncl. DATE � VALIDATION O Contrector�^�j r" t Date .Over 10 to 50 IncL , f"' ❑ - FINAL � a 61 U I am exempt under Sec. Over 50 to 1D0 Inc. gy, �� � Ov2r 100 B&PC.for.this reason � � � ,. �� . . . .� Servces,Svrod.,A4CC&Panelboards � -�-� �-�����-� -� � � Date: ;�-200 Amp.Undcr 800 V L � � Signature 20!-�1000 Amp.Urder�600 V �,"V�� � � �� ❑ ExemF��on for Reg.Mairrt.clect Gver�DOO.Amp.or Over.600 4 � �j �.' � _ � SINGLE FAMILY Temp.Pomrer Pole&ApWrfenances �{j J � HOME OVJNER-BilILDER DECLARATION Sign vrith One Branch Circuil ,. 'jb� � I here6y affirm that I am exempt from the Contractors License Lavd � � -. for the following reason(Section 7G3�a',Business and Rofessions Atltliliona�Si3n 9ranchCircuits . ,,. . _ , . . . „ �, Codet � U!sc.Conduits&Gonductors � � - � - �-� � . �- ��� - . I,as owner oi the property.wili do the work and the structure Other(See Con�,plete Fec-.Schedule)_ � is not intended cr offered(ar sale ISection 7044,Business � :� ''!.J F; and Professions Code}. � ��� - � � � � - �- CCNSTRUCTION LEN�WG AGENCY � - � ��� ����� ��«��� �. I hereby affirm Shat there is a construc;ion lending agency for the � -„ ,� � o,;�� pzrformance ef,h2 work fcr which this permit is issued�Sec.3097, PERA4iT FEE � (Su6-Tota��,1� . .. . . . .. . . . . .. Giv.G.l. � . � ' ° i ��;�U.u PLAN CHECKING FEE . � � .�. . � � Lender s Name � Q�',4 �--�j�j PERN'.IT ISSUING FEE �(� �C} � - � LenCer's Address - � � � � I certify that I have read[his application and statc that the zbove TOTAL FEE ���'� � � � - - � information is correct.!aore5 to comply wi[h all County;ordir�anCes _ . � � � -� � � � � � � -�� � � � and State laws regulating Electrical wiring, and here6y auihorize � � � � � � � � . � . _ representatives of this County�o enter upon;he abovermentioneC �- � � � -� -� � - -. � ' � �- �� � � � � � � -�� � � � � � � propert or inspection�purposes. � - -� � � �� SEE REVERSE FQJ�ExP�.ANATORY.LANGUAGE ,� , ._, . . _ . � . � � , � na ure ot Per �• � Date � � � � - - � � . � �. _,„_' : , . � ; _ �, ; � _ .,�_..__.�.—�...__.:m__�.__��__�._.__ .�_,__ _,_____._------_._.._____ _.__..__--__--- . � , _,. � � r _. _.___.______.___ ___._ _._�W__ _._._ _._w.__..__�.__. __ .___.---- ---_..__._..___ __..__. __.--. ____� .��.___._ , _ _._ _ __._� ,_ ,. .. _;.�;�, _;w_.�....__�_ - . . 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