HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPEPJSATION DECLARATION 76A663 toiei �
� I he�eby 2flirm that I have a certiiicate of consent to se!f insure, c680aG QPPLICATION FOR ELECTRICAL PERMIT
or a ceitificate of VJo�kcrs Compensafon Insumnce,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY
, copy thereof�(-SCe}c.380o.1ab.C.)
POIiCyNO�. ci �O�g�-�I'..mpany,�in ��T �A `}Sb, FORAPPLICANTTOFILLIN ' 'pB $y� V�� C S
� EACH NO. FEE A�oaESS O RC-(�h'� CT
Certified copy is hereby Furnished. New Residential Bldgs.8 ols � - '7' p.
hX � 1 8 2-Family,Sq.Ft. �3� � t — S $- LOCALITY �R��,S176-� �OI " p
L+�I Certified'copy is li.ed with the counly buildirg inspeCtion _ NEaieeSi
� depmtment. � Multi-famity Sq.Ft. �,�
O /�,�� C LRo55 ST.
Date�Q(�Applicant Residential Swimming Pools ' owriEa Oa.
/ �
FIRM NAME � C
CERTIFICATE OF EXEMPTION FROM LVORKERS' � - . � rAA�� `� l�
. �COti1P[NSAT1011 INSURANCE . . OWICIS:ReC—L'ght—Sw.— - AODRE55 S W C•
(7his sectlon need not be completed if the work involved by ihe F���20 CITY el.No.
permit is tor one hundred dollars($100)or lese.) � Total No. Additional - - �CJS� �g 6� ��-���
I Cerlify that in Ihe perform�nce aF the work for which this permit � \ APPLICANT K �
- is issued,I shail not empioy arry person in.ny mannM so as to � -.
become subiect to the l"Jo�kers'Compmsation Laws. Lighting Fiztures - First 20- ADDRESS
� Additional
I � -. . � � � - . Total No. � CI7Y - '� � Tel.No.
Oate Applicant Fized Appiiances Not Over 1 HP vEi�ti�it
NOTICE TO�APPUCANT: If, afler.making,ihis Certificate of < <
Exemption,you shouid berome subjec[to the NMrkers'Compensation Ran9e_ Heatcr_ O.W. _ . APPUCAM FC �\� ��L
provisions of lho Labor Codc,you must tortMrith comply wi!h such Oven_ Dryer_ W.M._ AD�RE55 .�_ g d- � �(
provisivns or this pe�mit shalt be deemed revoked . Top —FAU _ VJH._ CITY C�a(N� 1 r�$- Tel.No �-6�r 6
LICENSED CONTRACTORS DECLARATION Hood_Fan _ Other_
I hereby affirm that I am I�censed urider prov5ions of Chapter 9 . Dfsp. —Room Air Cord. — uCENSE oR L S?, Ciasx �1�
lcommencing with Section 70001 of Division 3 of the Business and REG.NU�.�BER �O� V 3 � 1
- Rofe55�on4 COd2,en�my IiCBnSC i5 ifl 1u1�fO�CC�nd C}fCCt. Powef Appalatus&LnrgO Appli�r�2S. DISTfiICT NO. PROCESSED BV
�_'0 Size 8 Type HP,KW,KVA,or KVAR �'�. CJ � �c�`L+A C �
p^� d
� License Number y 9(��O J Lic.Class Up to 1 Incl. FINAL U
DATE �
T �/ Over 1 to 101nc1. Z� VALIDATION �
Contractor C�N C/����� Date� Over 10 to 50 Incl. FINAL V
❑ 1 am exempt under Sec. Over 50 to 100 Inc. BY ..
W
0.8P.C.for this reason Over 10D � G.
-Services,Swbd.,MCC 8 Panel6oarCs - . �� �� � `n> > ���'F� z
Date: 0-200 Amp.Under 600 V � o , �
SignaWre 201-1000 Amp:Under 600 V - �� e�
-� - - Owr 1000 Amp.or Over 600 V � . ��a q g
Ezemplion for Reg Maint.Elect.
- - SINGLE FAti9LY � Temp.Power Pole 8 Appurtenances ' ' �'7����%�-
HOME O'.^MER-F3U!L�ER DECLARATION Sign with One�ranch CirCuil �
I hereby affirm that I am erempt from the Contractors License Law p,�,�;��,�,1 S�n Bn_.r_h G!c�its ��2 6-�&
for the following�eason(Section 7031.5,Business and Wofessions � � � ��- � � - �
Code):
will do iha work and lhe structure Misc Conduits&Conduclors � � � -
❑ I,as owner ot the property, Other(See Complete Fee Schedule)_
is not inteMed or oHereA for sa�e(Section 7044,8usiness _ ►
and Professions Codel.
. CONSTRUCTION LENDING AGENCY - - �
I hereby affirm that there is a construtlion lending agency for the
performance ot the work for whiCh Ihis permit is issued ISec.3097, . pERM1T FEE- � � (Sub-Total) �`j .. . . . .
Civ.CJ.
PLAN CHECKING FEE
lender's Name
PERMR ISSUING FEE . _ (� SC . .
LenCer's Address r
I certify ihat I have read lhis application and state that[he above 7UTAL FEE �J ,�S
informalion is carect I agree to comply with all Counry o�dinances
and State I�ws regulatirg Electrical wiring,and hereby authorize .
representztives of this County�o enter upon the zhove-mentioned � � � - -
properF for inspection purposes. SEE REYERSE FOP.EXPLANATORY LANGUAGE _ ..
c � ��
Signature oi Permittee D e
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