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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSAT�ON DECLARATION � 76Aefi3 i0/81 � � LE-BO6G APPLICATION FOR ELECTRICAL PERMIT I hereby affirm lhal I have a certificale ot consent to self insure, o�a ceniticate ot Workers'Compensation Insurance,or a certiticd COUNTY OF LOS ANGELES BUILDING AND SAFETY � copy thereof ISea 3BOO.Lab.C.) PorcvNo l 363comcarn�lJOua'tQ�AL �N�� FOflAPPLICANTTOFILLIN ' JOB ❑ Certilied co is here6 furnished.. . .. . EACH. N0. . .FEE AODaeSS g V� � C-q C DY . Y. , New Residentlal Bldgs.8 Pools � n!_ a ( L - ' S 2 g _ g LOCALITY; L r S/e V ��� Certified copy is filed with the county buildin9 inspection 1&2-Family,Sq.Ft. ` _ R �h - department: � � Multi-family Sq.Ft. NEMesi - yf�} CROSS ST. Date 30 � ` ApplicanR�'�wY �t���'� Residentisl Swimming Pools . � cnNNER oR FIRM NAME � ''L ��� �. CERTIFICATE OF EXEMPTION FROM WORKERS' puUets:Rec—Light_Sw.— � � - COMPENSATION INSURANCE � � � - ` � 'AD�RESS I SI � �J�. ' � (Thle section need nol be completed if the work Involyed by Ihe First 20 �permit Is for ane hundred dollars(S700)or less.) . Total No. Additional CIT�Q"tA M� �6ffl.No. � OO 1 certify th�t in tM1e perlormanco of the work for which ihis permit ,. . - ' qppL.µµ.i K. _. . is issued,�I shall not employ.a:ry person in arry manner so es to � . _ become subject to the Workers'Compens2tion Laws. _ L'gMing Fixtures First 20 ADDRESS- �� -�� � � � - � �� Total No. Additional CITY � � � Tel.No. �ale Applicant - Fixed Appiiances Not Over 7 HP NOTICE TO APPLICANT: II, alter making-this Certiticate of qp����M �� C �` �\CCT(ZLC Exemption,you should 6ecom=subject to lhe VM�kers'Compensation Range—Heater_�.W. _ I ADDRESS provisions of the Labor Code,you must forthwith comply with such Oven_IXyer_ W.M._ .Q, Q p \\\1 provisions or this permit shail be deemed rewked. _ Top. _FAU _,W.H._ CITY C���b 1 U Tel.No.��-�j�� LICENSED CONTRACTORS DECLARATION.. .. Hood_Fan _ Other_ I hereby aifirm that I am licensed under provisions of Chapter 9 Disp.-—Room Air Cond.-_ uCENSE OR L' O Q � __._. __ �wgA��/U (commencing wilh Section 70001 of Division 3 oF the Business and REG.NUIdBEH I ProFessions Code,antl rtry Ilcense is in(uIl force-and effect. ' poWer Apparatus 8 Large Appliances DISTR�CT NO. PfiOGESSED 6Y � I'p /1 Size 8 Type HP,KW,KVA,or KVAR .G 1 �\ �i l o Yl� �Q License Number 7 7�0�3 Lia Class `-��/� � �� ��Up to 1 IncL ��"-- -- � " � � " - FINAL �� �- - r-�//�� - - - -- v DATE «_�G"'27./ VALIDATION ,n pver 1 to 101nc1. O Contracror E��=G�'R�� a� Date�1�� �� � � pver 10 to 50-Incl. - ' - ❑ � . . . FINAL — .. . .. .. U I am exempt under Sec. Over 50 to.700 Inc. gy � W � B.&P.C.for this mason � O�er 100 � � � Services,Swbd.,MCC 8 Panelboards� � � � �� � .� z 1 1 b 2 A � � - --Date� - 0-200 Amp.UMer 600 V ► � � � � � Signature ... .-.201-1000 Amp.Uncler 600 V. .. . ... � . �. . .. . . . . . . .. .. -.... # 2 .. _. . . . ._.. .. -- -- ......_. � Over 1000 AmP.or Over 800 V ❑ Exemplion for Reg.MaiM.Elect -- � � . . � � �� � � � �� � ' • � 1 2.1 � � SINGLE FAMILY � � Temp.Povrer Pole 8 Appurtenances • ` � � 1.� ��u HOME 04VNER-BIJILDER DECLARATION Sign with One Branch Ciicui[ I herehy atfirm thzt I am exempt from the Contractor's License Law qdditional Sian Branch Circvits D&2 6-8 B for the fonowirg reason��ction 7031.5,6usiness and Rc'assions - Code�: � Misa Conduits 8 Conductors � � � � - - � - � ❑ I,as owner ot the property,will do tha work and[he structure Other�See Complete Fee Schedule)_ is not intended or offered for sale(Section 7044,Business � and Professions Cod=1. . . ..... ...... .... . .. �. . .. . . .. _. ... . . . . CONSTRUCTION LENDING AGENCY � � - - � - - - � �� - � I hereby alfirm Ihat ihere is a construction lending agerxy for lhe performance of the work for vrhich this permit Is issuetl(Sec.3097,.-. �pERMIT FEE�� -� � �- � - � ��(�6-Totaq �o/ � . . . - - CiV.C.1. . .. ._. . _. . . .-. PLAN CHECKING FEE. . . .... . . . ... . . . . , . ...... ...... . .... . .. . . .. . ... Lender's Name In _ PERMR ISSUING FEE . .. _ _ � � J�+ ., .. . ., .. _ . � Lender's Address //n +/ ' I certity ihat I have iead this application and s[ate ihat[he above TOTAL FEE p�� ._. ...__ . ._.. . ... .. . _ . . information is carect.I agree to comply with all Courrty ordina�es and State laws regulatirg Electiical wiring,and hereby autMrize � ' representatives ol Ihis Cwnty to enter upon ihe above•mentioned � -�� - --� � �� - �- " � - � -� -� ' � ' - property for inspection purpos s. _ _. 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