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HomeMy WebLinkAboutNo Permit Number (4) � WORKERS'COMPENSATIONDECLARATION 76A663 ,o,e, qppLICATION FOR ELECTRICAL PERMIT {� � I hereby aftirm that I have a certificale of consent to self insure, CE-sosG or a certifbate oF Workers'Compensatbn Insurance,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY �� copy them0f(Sec.3800.Lab.C.) Porcy No.CJ�plg3�3�m�m�1J Do sTR1A l 1 U b. FOR APPUCAM TO flLL IN JOB O. ❑ :Certified copy is hereby Furnished. , � .. New f7esidential Bldgs.& o 4C/ EACH NO. �FEE. ADoaE55 p � ��'�'� �o��S�Rtf�h1 � Certified copy is filed with the county buikling inspection 1 8 2-Family,Sq.Ff.��5�! g 0 =5 7 3 LOCALITY S �V {,0 �. department: -� / , _.� o' MUIII-f3mily Sq.FL � NEARESi � . y n^n , �9 O �$� �1 �������"/Q� ResideMi�t Swimming Pools CRO55 57. b�7i� Date �3 � Appiicant 1j�/� (riJNER OR ) � / � _ . ... FlRM NAME�Cl�m I ' � CEFiTIFlCATE OF EXEMPTION FROM VJORKERS' � � � ��_ MaiL COMPENSATION INSURANCE � . Oul�ets:Rec_Lk�ht_Sw._ � � ppoRESS I�� �r � 6- „ �� (Thla section need not be compteted if the work Involvetl by Ihe Fiist 20 permit is for one hundred dollars(4100)or leas.)- . Tolal No. Additional �� CITY. OS �S (�� 'N°' �O^(00 I CEfti(y-th0t ill ihe pPf10ff118nCf Of th@ WOfk 10f WhiCh IhiS pelmif PLN7 CHECK � is issued,I shall not empby.arry Person in arry manner so as to , ���C/Nt .. - become subject to the Wakers'Compensation Laws. . , Li9htirg Fiztures First 20��� A�DRESS- � � ' � � ' � � Total No. Additional,_ CITY-���- Tel.No. Dale Applicant � �� Fixed Apptiances Not Over 1 HP �NOTICE TO APPIJCANT: If, after making this Certificate of �MICANT�'�� C Cl ��C �C � ,Exemplion,you should become subject Jo the Workers'Compensation _ . Range�Heater_ D W. _ � p�ovisions of tFe Labor Code,you must forthwilh comply with such Oven_Dryer_ W.M._ _ ADORESS !�0 � �provisions or this permit shail 6e deemed revoked.. . . _ Top ._.FAU.._.W.H._ . . LICENSED COP7TRACTORS DECLARATION ,.. Hood_Fan — Other_ , qTY �� O � � Tel.No.,j`�/-(� � I hereby�alfirm ihat I am licensed under provisions of Chapter 9 . uCeNseoa (Commencing with SecliOn 7000)of Division 3 of the Bu5ine5S and Disp: _Room�Air Cond.�— � REG.NUMBER � -�p 3 � ���a'x -�a Professions Code,and my Iicense is in full}orce and effecL p�r Apparatus 8 Lar9e ApO�iances.. . .. oi5miL7 No. Pa0ce5Seo sv ,/�y p Size 8 Type HP,KW,KVA,o�KUAF D �q 1p��e � Lkense Number 7 /�d o� Lic.Class �'�p � � � Up to 1 Incl.� � � - � FlNAL � ,p/ -�� � __t/�C7.RCC.�f _. ,,/n n .- Over 1 to 101nc1. , . DATE f^�.--,�Q �,( yAL1DAT10N . � � Coutractor e 1 L Date Y�«-7 C� CJ" . . .. Over 10 to 50 Incl. FlNAL V ❑. I am exempt under Sec. Over 50 to 100 Inc.__. gy W � � � B.&P.C.For this reason Over 700 . � � . .. Services,Swbd.,MCC 8 Panelboards ''� " S ' � -� ��' 1 7;�n Z I ' Date: � 0-200 Amp.Urdcr�00 V � Sign2ture _ 201--f000 Amp:UnCer 600 V - -�--- " - �� " � � �" � � " -- ❑ pver 1000 Amp.or Over 600 V _ �� ° � �2 Exemption for Reg.Maint.Elect. � SINGLE FAMILV - -�� . .Temp.Power Pole 8 Appurtenances . , � � • •s�3 8 6 . HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � • e �8,�j,fj(�� I hereby a(ti�m Ihzt I am exempt from ihe Contrector's License Law 1or the follpwing rnason(Sactinn 7071b,Bo5��5s znd Prefessions � Additional Siqn BranCh Circuils �� - � . . - ���: 0&26-88 Misc:Conduits 8 Condudors- � �-� - " - - - � � �� � � ' ❑ I,as owner of the pro0erty,will do the wo�k and the structure is not intended or offered for sale(Section 704a,Business _ Other�See Compiete Fee Scheduie)_ ► and Pmfessions Code). CONSTRUCTION LENOING AGENCY � - - - � I hem6y aftiim that there is a constmction IeMing:x�ency(or the performance of the vrork for which this permit is issued(Sec.3097, - pERMR FEE ' - � � �� (Sub-Total) � s � � � ��- -� � CN.C.). . PLAN CHECKING FEE � -- � - � - - - � ��- -- ��� �� - � - - Lender's Name � PERMIT�SSUING FEE . - . . ._ O D . -- . . . - .- _ . . Lenders Address � I certify that I have read this application arM state that the above . TOTA�FEE._ . . . .. . . . gS �6 _ _ _ _. . . .. information is correct.1 a9mo to comply with all Counry ordinarxes �aM State laws regulating Elecfrical wiring,and hereby authorize . _ _ . .. . representalives of ihis Counry to en�er upon Ihe above-mentioned prpp rty forinspeclion purp ses. . �yJ 2 ¢¢ �- - --��� �SEEREVERSEFORE%PLANATORYLANGUAGE � - - � � -� -� � --� � . . � //' C 6 �C.� V V ' . . Signature ot Permittce Dat . �!J'. ' .__��� ' ' � .. . ..�.�.�.... �.�.�. . 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