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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION 7snssa ioie� � � CE-BO6G APPLICATION FOR ELECTRICAL PERMIT {� I herebyaffirm that I have a certificate ol consent to self insure, . 1� or a certificzte of Workers'Compensalion Insurance,or a certi�ied COUNTY OF LOS ANGELES BUILDING AND SAFETY L copy therenof(Sqec.380-0i�.Lab.Q) Policy No.`i� IOI�-�b3Company��nUST'+Z�f�L `ND� FOR APPLICANT TO Flll IN� - ' � ' dOB � � � y r � EACH NO. ,..FEE. .._ AODRe55$O Co c 1 FAtr. Certified coOY is hereby furnished. New Residential Bldgs.8 ois '- - S _ S LOCALRY 2 S96—V �d� ' � Certified copy is filed with the county 6uildirg inspec[ion 1 8 2-Family,Sq.Ft _ tleDariment. . . Multi-family Sq.FL NEnREST� � �,. CROSS SL -o� Date�Q�_Applican Rezidential Swimming Pools � � p�,yNEq Oia /� FlRM NAME �T 17'� C • CEFiT1FICATE OF EXEMPTIOt�FROM WORKERS' � Ou[lets:Rec—L'yht_Sw.— � �� � .COMPENSATIONINSURANCE� � � � - - � ao0ae55 SI W U�."�N (This setllon need not be compieled if the work Involved by the . First 20� permit Is for one hundred dollars($100)or leas.) Total No. - Additionat CIT�o TA� g� � Tel.No. �.. � PLAN CHECK �I certify that in thZ pBffOfrtlBflCB 01 thB wOfk(Of WhfCh thi5 pPrmit ' ' � pFPLIGM - - — is issued,I shali not employ�any person in arry manner so as to — � become subject to the Nbrkers'Compensation Laws. L'ghting Fixtures Frst 20 - ADDRESS � � �� � � � � Addltlonal . . � - : Tel.No. Total No. CITY Data Applicant Faed Appliances Not Ove�1 NP - PeaMii � .NOTICE TO'APPLICANT: If, after making Ihis Certificate of ppp��qM� � � �C C `, `C Q\C � �Exemption,you shouM become subiect to ihe Workers'Compensation . Range_Heater_ D.W. _ _ _ I ,provisions ot iha Labor Coda,you must forthwiih comply with suCh Ucn_Lwy=r_ W.M._ AODRE55 � � � � -provislons or this permit shall be deemed rewked. . � . .Top _ FAU._ W.H._ , � I LICENSED CONTRACTORS DECLARATION �. CITY � �p 1 Tel.No.s 9'1-6 �j •. , Hood— Fan _ Other_ � I hereby,aifirm th2t I am Iiten5e0 untler provisions of Chapter 9 uCENSEOR p Class. ^ Disp.--Room Air Card.���_- - -- REG.NUMBER � OO p -- 1� � (eommencing with Section 7000)of Divislon 3 of the Business and � Professions Code,and my license is in full force and e(lect . .po�.,yr ADParetus S Large App�iances _ DiSmiCE No. PnOCESSED BY ' � 1l� 1"�c�`c.r� c°.> � ry Size&Type HP,KW,KVA,orvKVAR License Number y q o o�e a Uc.Class`��b � � Up to 1�Incl.�� �� � � . � FlNAL - � t Over 7 to 10 Incl. DATE 'l^l p�� VALIDATON _ _ p G a � Contrector � CCTR�C�C �� oare [�$9. Over 10 to 50 Incl. FINAL (~j ❑ I am exempt undei Sec. Over 50 to 700 Inc. 8Y � - - --- � B.dP.C.tor this reason Over 100 N • - Services;Svrbd.,MCC&PanAtboards � � �-�� --� - - �" �� � � Z � � - --�- � - 03t0:- -� 0-200 Amp.Under 600 V , ."1 1 Z 1 r3 Signature 201-1000 Amp.Under 600 V ' ��� � � - � ��� �. . e - ❑ . . - . . � Over 1000 Amp.or Over 600.V.. . .. _. . . . . . �' . 'G Exemption for Reg.Maint.Elect. I • •9626 � � � SINGLE FAMILY � � � Temp.Power Pole 8 AppuAenances .,. _ _. . . _ . ... M HOME OWNER-BUILDER DECLARATION Sign wilh One Branch Circuit • o •C�%�j�; I here6y affirm Ihal I am exempt from the Con!ractor's License Law ��n��onal S',ryn Branch Circuits � ' for the following reason�Section 703�.5,susiness ane Pro�essions . O��2 6—B B� codel: Misa Conduils&Conductors � - - � �� � � � � - � �� � � ❑ I,as owner of the proDerty,will do ihe work and the structure Other�See Complete Fee Schedute)_ is not intended or offe�ed(or sale(Section 7044,Business _ . .. . .._ _ . . . . . . and Professions Codel. ► CONSTRUCTION LENDING AGENCY �� � �� - � � - . 1 hereby atfirm th�t[here is a construdion lerxlirg agency lor the � performance of the work tor which this permit is issued(SeC.3097, �� pERMfT FEE � � - (Sub-Tot2q � $`S 6� �� �� � � Civ.C.). ' - .. .PLAN CHECKING FEE...... . . ..... ..._.. . ... .. .. _. _ ._ .. _. . .... . . . . Lender's Name � � .PERMIT ISSUING FEE.. . _ .. . . .. .. . � �U- O --� � � � �.�� � - Lenders Address r�/ � I certify that I have read[his application and state that the above TOTAL FEE . . _. .. q�j.{b . _ . . .. . . .. - .-. inPormation is correct.I agme to comply with all Counry ordinances and State laws regulating Electrical wirin9,and.he�eby authorize . _ _ ._ _ , . . . . . . ... . . . . .. 2presentatives of this.County to enter upon the above-mentioned , , propert for inspedion r oses - .- SEE REVERSE FOR EXPLANATORY LANGUAGE- �� - � � � - � - ��� � �� Sign,,ture of Permittee Dal - �,;:-.•,:-,.�: r-----� i.._.._... . .. ,..._ . �.__�i i-- -";. '' j� '-�------�1--�-'. _i I.�..I'!-I--i � ' � _ I ' � I � � I �i . �. � . �._ �•.. � ; , . �` �_ � - � !_ - � !� . ; �� ;��_ � __ I-- � ; i - i i i _ i._ +�`- _ ` -. _ ... i .i � - i � I � � ' ;�_ ! , i ' l'.' i . � � � • . _. '._ _:�.�. _ � ' r- i . ' ' ; . i- i ' � �` : I � . � 1 . . � �.: r. � ' �•. !' 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