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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATION DECLARATION 76A883 toie� � , �E.eosa APPLICATIDN FOR ELECTRICAL PERMIT I here6y affirm that I have a certificate of consent to self insuro, . or a certificale of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) . PolicyNo.C�q�Ig363�mpary.��D��5T�1A� WO FORAPPLICANTTOFlLLIN ��B �Y �1 �`l C 1 I � EACH N0. - FEE. ADDftE55 OU O S CZ�N�fYI � -Certilied copy is hereby furnished. New Residen[ial Bldgs.8 Poo_I�,.,� �O _ � �S �pCAUTY � 2S�(a—V LpT �3 � Certilietl copy is filetl with the county buiMing inspection 1&2-Family,Sq.Ft. 1 ?3'`f _ . department. � � - � � 1 Multi-tamily Sq.Ft. NeaaeST � � `J ��`���rrrvvv��� 9l CRO55 ST. —1`� —`q/��n Residential Swimmirg Pools Date 30 APPlicant�,y�-- �• -GT� ' OWNER OR ' � . FIRMNAME YY�(} C � • � CERTIFICATE OF EXEMPTION FROM WORKERS' � � �- � - MA�� n Outleis:Rec—Light_Sw.— „ �� � �-- COMPENSATIONINSURANCE � � ADDRE55-�ISI- Rw`F U (This seclion need not be eompleted if Ihe work imolved by tha Frst 20� CIT�(� el.No.p, permit is for ane hundred dollars(5100)or leas.), . .� Total No. AddiCronal 'LUS ll$�b��00 . PLAN GHECK I certify that in the p=rlermarxe of the work�er which this permit � " � AmuCANT � � � � _ is issued,I shall not employ any person in arry manner so as to . _ become subject to the Vlorkers'Canpensation Laws. L'ghting Fixtures First 20�- � ADDRESS� � �� � � � � �� � ' - � � � .. Tolal No. Additional _ CITY � � � Tel.No. Date - App�icanF � � Fxed Appliances Not Over 1 HP pEqMii u NOTICE TO APPLICANT:-II; alter.,making this-Certificate of ppp�CqM � Ft E��C Exemption,yrn�shou�d become subjed to the Workers'Compensation Range_Heater_ D.W. _ _ pr�vi�ions cl the L;6or Code,�rou must Forthwith comply with such Oven_Dryer_ W.M._ A�DRESS _O' �o j� ��� provisions or this permit shzll be deemed rewked. ..Top _FAU _ W.H.._ - ' �GRY� � 1���. Tfl.No.� _ LICENSED CONTRACTORS DECIARATION,� � Hootl_ Fan _ Other_ 1�ere6y affirm that I am licensed under pmvisions ot.Chapter 9 .. ����pis � Room Air Cond.� - - . . __ uCeNse on . 4 p O O q,� _ ... qass (commencing with Section 7000)of Division 3 of[he Business and p� — REG.NUMeER l O '(G Professions Code,and my Iicense is in full foice and elfect. power Apparetus&Large Appliances _ . . � oisTaiCt NO. * PRocE55Eo 9Y Size 8 Type HP,K1N,KVA,or KVAR l C./ � ' \0.`C�h C �4 License Number �900 R 3 LiC.Class C��� � � � lJp to�1 Incl. � �� � FlNAL �/� -- " Contractor ��ECT��C/�L oate'��_ ' ovzr 1 to 101nc1. DATE '1 L�d/ VALIDp110N.. ... a L - O1... Over 10 to 50 InGI. FINAL }' ❑ I am eKempt under Sea .��- Over 50 to 1DO Inc._ gy _ ..._ . . .. �y B.&P.C.Fo�ihis reason Over 700 N ... ..__.. ... . � �Services,Swbd:.MCC 8 Panelboards... . . -. . . . . . ... .. . . - . Z oat�: - - _ ;1 1 8.�3 A 0-200 Amp.Under 600 V � Signature 207-1000 Amp.Under 600 V�� � � �w . s e •2 ❑ � ' " �"� � ' Over 1000 Amp.or Over 600 V Exemption for ReO�Maint Elect. � a 1 G r�4 tJ -- - � - SINGLE FAMILY�- - -� � Temp.Povrer Pole d Appurtenxnces . „ . . .... _ HOME OF✓NER-BUILDER DECLARATION Sign with One Branch Circuit . - ° • 1�<�h�:,5 I hereby alfirm that I am exempt lrom ihe Contrador's License Law for the follpwing reason(Section 7031.5,Business ard Professions " �`�'���^'�S'��Frnm,h Cirant» - � � �--'�� - - '� G b L C—O O Code): ❑ ' � � �Misa Conduits 8 Condudors� � � � � � � � � I,as owner of the property,wil�do lhe work and the structure Olher(See Complete Fee Schedule)_ is not intended or oflered fa sale(Section 7044,Business . , � _ .__. . . . . . ... . . and Protessions Codel. CONSTRUCTION LEN�ING AGENCY - - � '� --- � � �- ���� � � I hereby atfirm that there is a construction IeMirg agency for the ! . � performance of lhe wo�k foi which Ihis permit Is issved(Sec.3097, � pERMIT FEE- -- - --- � - (�b-Totaq ��s 9b - ' � Civ.C.). � PI.AN CHECKING FEE � � - � � �� - - � � Lender's Name ... PERMIT ISSUING FEE -� ...-. �O SQ ._ . _ . ._ Lender's Address I certify Ihat I have re20 thls application aM state that the above T07AL FEE � . /2�j• Y6 . . . . - informa[ion is correcL I egree to comply with all Cwnty ordinances antl State laws re9ulatin9�Electrical wiring,zrd hereby authorize . . � . . . . . . . _ ..... . ... . . .__ ..._. -- representatives of this County to enter upon the above-mentioned . property for inspection purpose. � - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ot Permittee C �� . ._. .._ . .. .. . . . . ... . .. . � . .__ _ :t:.�. „ . . ---- . . . i,�..' . �_._..... _ �"- i � : I � � - ; � � . ; . �_ � � .. ! i � I-_. i. - : i . . i � - I �j'- , '� � - 1 1 � I I i " i. ; I I-_ � � . . ,i i i. � i I .. � I '�' I - . -�I ' , ' � i ".. i i . . _'':. i '� .. - i - - - -� I � , , �� , + _ ti ': I _ � z_ =n v -n s _�o' c � � ' � � o -- � o x O z m. . 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