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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSAPON DECLARATION 76A663 70/et � � CE-BO6� APPLICATION FOR ELECTRICAL PERMIT I hereby affirm Ihat I have a certi?icate of consent to self insure, or a certiticate of Workers'Comoensation Inwrance,or a certitied COUNTY OF LOS ANGELES BUILDING AN�SAFETY .copy thereof(Sec.38p00.Lab.C.) � . POfICJ N. - O O��pmp�m,IA1 A���P.1 A L C�UD. FOR APPLICANT TO FlLL IN pDF7E55 V � I RF ir C ❑. Certified copy is hereby furnished... . . . New Residential Bldgs.&�I}�QQ' EACH NO. .- . FEE. � 1 8 2-Family,Sq.Ft.�' 1— S� — S �.5 LOCALITY �57 �V O�+ ��- Certified co{iy is filed with ihe�county building inspection _ . department. : Multi-family Sq.Ft. NEnaEST „�/ ; ��'�/ caoss sr. Oale 30 � Applicant�9^� �pl� Residential Swimming Pools � � � � pwwEa oR FIRM NAME q � � CERTIFICATE OF E%EMPTION FROM WORKERS' putlets:Rec—Light_Sw._. .. �- . MAi� `� ' 4 �� - COMPENSATIONINSURANCE �� - . � � - � pDDRESS � � W V L• (Thls sectlon need nat be completad if the work involved by the Flrst 20 p�-.�, permit fs tor ona hundred doltars($100)or less.) Total No. -Additional ��TY S �6 �N�� oJ V^� I certify that in thc pertormance of the vrork for which this permi[ "� , PLAN CHECK . �APPLICANT — is issue4 I shall�not employ arry person in arry manner SO as to � _ become subjed to the Wmkers'Compensation Laws.. ..,.- L'ghting Fixtures Frst 20� - --�- -- � -— - AD�RESS � � �� � � � � - � . Total No. Additional CT� - � � � Tel.No. Date �Applicant � Fixed Appliances Not Over 1 HP PEF7MIT v NOTICE TO.APPLICANT: If, atter makin9�this Certificate o1 ppp���µM C �' rN �`�C�R\� Exemptbn,you should become whject to[he Workers Compensation _ Ran9e_Heafer_ D.W. _ ,. µ _ _. . provisions of the Labor Code,yov must tor1M•+i;h comF�Y with yuch Own_Oryer_W M._ AODRESS _� '� ��, provisions or this permit shail 6e deemed revoked. .... .. Top —FAU. _W.H._, . .. CITY C� ����' Tel.No.�I.(�j 6 � LICENSED CONTRACTORS OECLAPATION Nood— Fan _Other_ 1 hereby alfirm that I am licensed under provisions o�Ch3pter 9 � Dis - RODm Aif CAnd. — LiCENSE OR L p Q � Class. P�= REG.NUMBER 1 OO U� C`�d (commencing with Sxtion 7000)oF Division 3 01 the Business and � Professions Code,and my license is in full force and eHect. po�.,�r Apparetus&Large Appliances DISTf11CT NO. PI70CESSED 6Y Size 8 Type HP,KW,KUA,or KVAR � 1 ��0.�!�n � � I License Number y 9 a o $3 Lia Class ���� � � � � Llp to 1�Incl. ��-- �� � -� � � FINAL ' -- - �� � u � Over 1 ta 10 Incl. DATE r}� .h/� VALIDA710N 0 Contractor E�CC�REC A-L Date� (> CJ► ❑ Over 10 to 50 Irxl. . - . . . _ . . . . .. V FINAL I am exemp[untler Sec. Qver 50 to 100 Inc. BY-� W B.SP.C.tor Ihis reason Over 100 C. N .__. . _ .. . ... .. . . Services,Swbd.,MCC 8 Panelboards � - -" ��� "-�� - � � � � � � - Z ���Oatef- " 0-200 Amp.U�der 600 V :1 1 9,C n — Signature � ��� 201=1000 Amp.Under 600 V - - ��- � �� �� �� - - . ... .-. .. . .... . . . Over 1000 AmP.a�r 600 V �.. • s . '2 � Exemption�Or Rpg.MaiM.Elect. -� � � � �� � � � �� � - - � - 1 � 12b46 � � ������ SINGLE FAMILY -� Temp.Pbwer Pole&Appurtenances . . HOME 01VNER-BUILDER DECLARATION Sign with One Brarxh Circuit • o � ����C G u 1 hereby affirm that I am exempt from the Conhactor's License Law �,,�„nal Sgn Brznth Circuits -���� � � �-� lor the followinq reason(Section 7o31b.Business and Protessions 0�z b—�� Code): . . - '- .,... . . .. ❑ Misa Conduits 8 Conductors� �� �� �� � -� - I,as owner o1 the property,will do the work and the structure Other�See Complete Fee Schedule)_ is rrot interded or otiered tor saie(Section 7044,Business _ . . . . ... _ , - --- �� - antl Professions Codel. CONSTRUCTION LENDiNG AGENCY -- � ��- � �� �� � � 1 hereby alfirm that there is a construction lendirg agency For the -performance of[he work for which thig permlt is issued(Sec.3097, pERM1T FEE , � � � ' (Sub-Totaq S �, --- - �-�` � - � �� � � ' Civ.C.). � PLAN CNECKWG FEE-� -- -� � � � � � - - - - Lender's Name PERMR ISSUING FEE � . ._ . . . ._.... . Q D - .� � . � Lender's Atl�ress . /�6.�i I certify that I have read Ihls application and state that the above 7'OTAI FEE . D . . � inlorma[ion is correct.I agme to comply with all Cwnty ordinances . and State laws regulating Electrical wirirg,and hereby authorize ' representatives of this Counry to enter upon lhe above-mentioned . � property for inspection purpose . _ .- SEE REVERSE FOR E%PLANATORY LANGUAGE � - - -- - � �� � � � � / � W f� � $ 2z �'S� Si<,ature ot F'ermrttee D te ..��:..._......__,... _ . . 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