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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATIONDECLAFATION 76A663 �o,e, qppLICATION FOR ELECTRICAL PERMIT � {� � I hereby alfirm thz[I have a certificate oF consent to seiF insure, CE-Bo6G or a certificate of Workers'Compensatron Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY �� , copy thereof�Sec.38p00,Lab.C.) Policy No.� U� Company-1����IRL �N b_ FOH APPLICANT TO FILL IN � - JOB `1 . ,❑ Certified copy is hereby furnished. , � EACH.. NO. .FEE. AoorsESs�� �U `l S�RC-f}Y^ . . , New Residential Bldgs.8 I 1� -� Certified copy is fiied with the�county building inspection 1 8 2-Family,Sq.Ft. �� � = S O � LOCALIT a S�!�- O : y� NEAREST , � ode ar[menL ' Multidamily Sq.FL CROSS ST. 1' '30 �ig � �' � � Residential Swimming Pools - . owNeq oH _ Dale Applicant FiqM NAME (a . -CERTIFICATE OF EXEMPTION FROM WORKERS' putlets:Rec—L'ght—Sw.— �`�� �� - .COMPENSATION INSURANCE � . . - - � " ADDaESS� S V F. (This section need not 6e comple[ed if the work Involved by the First 20 qTY/y .No.p permll Is for one hundred dollars(5100)or le9s.) Total No. Addition�l � - - `aS� (]SO^�� I certify that,in tiw performance of the work for WhiCh lhi5 pBfmil ' �, ' APpUCANT K � _) is issued,1 shail not emp!oy any.person in any mannei so as to ' �i� _ become sublect to the Workers'Compensation Laws. , . L'ghtirg Fixtures First 20 ADORESS � - -�- - ' � '� � Total No. Additional ... . . : �� CITY .� . .. .. .- ... -' Tel.No. Date Applicent Fixed Appliances Not Over 1 HP �NOTICE �.TO APPLICANT: It, aller. making.this Certificate of - PERMI7 `• '� C ��C- 'C ��C. ,Exemption,you should become subject lo the Workers'Compensation Range_ Heater_ D W. _ A�iCANT . __ .. . . .. . .. . . . ,provi=_ions of IM Laher Ced�,}rou must lerthwith cemp�y wiih svch Oven_Dryer_ W.M._ ADDRESS prrnisions or this permit shatl be deemed revoked. , � _Top _ FAU _ W.H._ � . , . UCENSEO CONTRACTORS DECLARATION- � Hootl—Fan _ Other_ CITY � `l� Tel.No. �� 6� . .I h2�Eby aftirm ihat 1 Zm liCensed ufld@f,pfOvi5i0n5 Of ChdPt2r 9 DiSp. —ROOm Alf Cqnd.-� LJCENSE OR L ���g (commencing v�ith Sedion 7000)of Division 3 of the 6usiness and � AEG.NUMBER 0 ��� Rofe55i0n5 Code,and rtry licen5e i5 in full forCe and e}lect. ' DISTRICT NO. F'ROCESSED BY Power ApParatus 8 Large Appliances �h � � �c�7 �{ Size&Type HP,KW,KVA,or KVAR � . t O ```p\p�� L Q� � License Number �Op"J Lia Class �"' l o � Up to 1 IncL��� �- � � - FlNAL - -� � � - O I Over 7 to 701nCi. DATE ^7 "79 VALIDATION � � Contracta�IECr(:IC�L �Date�� � �� � pv�i�t0�to SOlncl. - r�� � � FINAL H j ❑ I am exempt untler Sec. Over 50 to 700 Inc. BY . . . W I B&P.C.for this reason Over 100 (y f �� Servims,Swbd.,MCC 8 Panclbomds � , Z . _ ..... ._ . i . ._ .. Date:.__ - ._--- o-zoo artm.u�de�soo v ^ Signaturo 20t-t000 Amp.Under soo V -- � � ����-(x 3 A .� . . . -. . ..- .-. ' . Over 1000 AmP.or Over 600.V . . .. . + • e � Exemption for Reg.Maint Elect. . ft• e 2. --��� -� � SINGLE FAM.ILY �� ""' ��� Temp.Power Pole 8 Appurtenances � HOME OVJNER-BUILDER DECLARATION Sign with One Branth Circuit � '�� � 7�� 8� I hereby atfirm that I am exempt irom the Contractor's License Law for Ihe lollowing reason(Seclion 7031.5,Business arM Professions Additional S�9n Br2rrh Cir�iite . . .. .. . _ _. ._.. o ,;.� j_�,� �,� Code�: ❑ I,as owner ot the property,will do Ihe work and the structure� Misa Conduits 8 Conductors - � � - - -- �--- 0�L G-B$ - is not intended or offered for saie(Section 7044,8usiness Other(See Complele Fee Schedule)_ antl Protessions Cotlel. �� ' � - - �� -��- �� � - CONSTFtUCT10N LENDWG AGENCY � - �� - - � - - � �� -�� � - ��� � I hereby affirm that there is a construction lerdirg a9ency for the � � perform2nce of the vrork for which this permit is issued(Sec.3097, pERMR FEE � � � -- ISub-Totaq J�/ _ . ....... .. . ... Civ.CJ. PLAN CHECKING FEE . . . _ . . . . .. Lender's Name PERMR ISSUING FEE _ Q � Lendeis Address � � I certiry that I have read this aDPlication ond state Ihat[he above . TOTAL FEE ' �,/�a/� information is correc�.I agree to comply with all County adinances - " ana State laws reguiating Electric2t wiring,and hereby aNhorize 2presentatives ot this County to enter upon the above•mentioned - '�� '' �' � ' � - -"' " � "" ""�� � "�" � . .. . .. _. . . . . . proper (orinspection purposes � �, . _ . . SEE REVERSE FOR EXPLANATORY LANGUAGE. . . . ._ . .. . _. _ 8 � Signature of Permrttee ate . ' ::;... _ ._ ;_ _.. '-r i • _ _ .i _I� .i__ .i..._i_,_.__.i ,:`=_'.�._. . _ _` i i , � j � -. 1 : I' i ' ' � � �,-- '. � I ` ! i �= I 1 ; � I . I..._. ' i � ' - i 1 I � _ ; 'I ,_ � I j " I i i; ' i" ; _ t � � � �, '. I � � J� ' .: ', ' ,,_ . . ` ' • , _ - 1 ' -, - -'-' --- -�- - � _. � ' � i ' _ � ' .. , __ � i (u _ I / I � i.J . ^ T ! � T .S I`� � ��. 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