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HomeMy WebLinkAbout1695A (10) _ __ _ _ - -- . _ _ Lr3Z,�C-'g-. -�� ,��. vVUNKERS�COMPENSATiONDEGLARATION � �sABc,3 ���s� qppLICATIf)N F�R ELE�TRICAL PERMIT � . ��'' � cE-ansc I hereby aFfirm'.hat 1 have a certificzte of conseni[o selt insuie or a certificatz of NOrkers Compensztion Insurance or a certified COUNTY O� LOS ANGCLE$ .., BUIL�ING AND SAFETY z .. :.)1. � � Gc�a..D.S"l�1ZlN�c. copy thereof(Sea..800,La6 CJ - ,r !J�� � j ...r ..�fl �:::.. ,� . .- ..,,...�.�.. . POl�icy No. -�"�GOfnpem,/ �..'..'.'..�.. ,FOR APPLICAN7 70 FILL IN ... .,,.... .108 � ' . Lf��. � � EAGH NO �FEE ADORESS Certified copy is hereby furnished. New Residential Bldgs&Pools � � . _ � LOCALITY ` m � Certifietl copy is !i!etl viith .he county build�ng ir.spec!ion. �a 2-Family,Sq.FL , :w.. � NEAREST •J . ^ � j ,+n�1 department. - � ..,..�.. -� �� MuCi',arnily Sq.Ft. CaCSs�. � [LL /�� 4lei�e-+ Date� � � �Applicant -. Resi�entia�S�s�imming Pools . O4VNER OR � ��1 . : �.,...,` ��66 . (This section need not be completed if the work involved 6y�the y I . � � CD'�'��'ME L�. j � CERTIFICATE OF EXEMPTION FROM WORKERS' pWlets:Rec�2 Light�S.v,iL2 � I�Q�' _ �*t?:. �Ci-"�. �'�� COMPENSATIONINSURANCE Q DRE55 ._. � q First 20 ermit is for one hundred dollars($7D0)or fess.y Total No. �• � ACditional t TY�,� �� ��7 L��Ip�� LiL. p . � . PLAN CHFCK i cert�fy that in the�perterroance of the�^.ork for vih�ch?his oe�mit I aPVUCaN7.,_, is issued,I shall not empioy any person in ary msnner so as tr . hecome subject to the Nlorkers'Compensztio�Laws ����� Lightiny Fixtuies First 2D-�-. �� � ADDRESS�l�Q(�i jj ��\ . .. � !�� Additiana� � .-� � Total No. �... � CITY�� a �� � x Date ,. Appllcant � ����� , �-�-� � �� Fixed ApF�iances Not Over 1 HP ... � pERMR � - NOTIGE TO APPLICANT: Ir, af[er making this Certificate of - I qppLl.^,atiT � ��� � Exemption,you should become subject to the Workers'Compensation Range_ Heaier_ �4V _ , � �� , provisions of the Labor Code,you must(orthwiih compl'y with such Oven �. Oryer J W.M.� I� ADDRE55 ,..... ..� � � �� � provisions or this permit shal;be deemetl revoked. ., . � Top -- FAU .,^INH._ I � CITY � Tel,Na � � _,_ LIGENSEO CONTRAGTORS DECLARATION Hood— Fan _ Other_ �� � ��� � I herzUy afflrm tha(I am licensed under prcvisions of Cnapter 9 Disp. .-- Room Air�Cond uGENSE ort : , :Class. . � — REG.�'UMBER , . . � .,� � (commencing v.nth SeCtion 70001 oi Oivision 3 0`the Business and pISTRIGT NO. PROCES Bv Professions Code,and my license is in full force and etfeci. Powe!Apparatus 8 L2rge Appliances � a Si TyfPy��HP.K�`J.KVA,or KVAR �! .qd, � U License Number Lia Class '����'Up ro 1 IncL ��+ '/ G�f[� � FINAL � Over 1 to 1C Incl. DATE � VALIDATION p Contractor -Date Over 10 fo 50 Incl. FINAL (� � ❑ I am exempt under Sec. - �.����-�� � _ - . Over 50 to iop Inc. ' BY ��� �G� 5� a B.&P.G.for this re2son � <.• Over 100 N _ - -� Se�viCes,S^ibd..A4CC&Panelboards �� B � , {`f Q c o e j �f Z .. . . .:.... Date�. � p �pp qmp.Under 600 V - Sign2ture � � 20��-1000 Amo.Under 600 V � �2��"��G �❑ � �� � � � Over 1000 Amp.or Over 600 V �� � �� - Exemption for Reg.Maint.Elect / �e �`�4 ���� SINGLE FAMILY. Temp.Prnver Pcle&Appurtenances � � �,`� � ��.G ri'��5 HOME OYJNER-BUILDER�EGLARATION Si5n with On=Brar,ch Circ�it � I hereby affirm that I am exempt from ihe Coniractor's L�cense l.zm Additional Sien Branch Circi.iits tor the fotiowing reason i5ection 7031 a,8usinesc and Professions Code1: ❑ ' AAlsc.Conduits&Gonauctars . � . � I,as owner ot the properry,evill do the�xork and tne strucmre Dfher(See Complete Fee Schedule)_ is not intendeC or oifered for sale(Section 7044.Business , and Proiessicns Code). CONSTRUCTION LENOING AGENCY I hereby affirm thai ihere is a construction lentling aGency,'or the . .. . .�.....:.. �.:._.... ..�,.. performance of ihe vrork for which this permit is issued ISec.3097, PERMIT FEE � (Suh-Totaq Q Civ.C.1. t p� .j ,r�/� t:"„�""`-' PLAN GHECKMG FEE ,iy,7�/� �OOi/✓��Gl.' �lrpF Il� .LenCer's Name � � .�� PERMIT ISSUING FEE I --- � Lenders Adtlress � � � �� � I certify that I have read this applica?ion 2nd state tha..he above TOTAL FEE . ���"� � , . . . .-ea, ;�:,..._ , _ _;.. o .: informe!io.^.is cOrrect.I agree to comply with an Couory ordinances - . .. . �� and Siffie laws regulating Electrical•,viring. arid hereb;% a�dhorize - � �..:� - � '� � .. � _ . .. . ._.. .. .._ . _ . represent2tiv¢s of thls County!o entar upon the above-meniioned � � _ -�.��.. " �� � �� � -. � �- � �� property fqr inspection purposes. ` " � � � . � � � . . 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