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HomeMy WebLinkAbout0874A (4) 1NDRKERS'COMPENSATION DECLARATION 76ase3 �a,s, .q�p�ICATIOIV���FOR ELECTRI�CAL��PERM�IT I hereby affirm that I have a certificate of consent to selt insure, ce-aosG - � or a certificate of Workers'C6mpensation Insucance,or a certifietl COUNTY OF LOS ANGELES BUILDING AND SAFETY - . copy thereof(Sec.3800,Lab.C.)� , � �FOHAPPLICAN770FfLL�IN "-"" --' '� ilOB �'�� �l -�' ,'/ �/ �,/ \ PolicyNo ����� Compamj� � - ADORESs� !J s���� (,il�'a1"�"jy(e�-�7 �^�• �. Certrfied copy is herehy fµ�nisl�ed . .. �„ ..�. New Residential Bldgs.&Pools EACH NO. FE& � . . . .. -� $ — � , LOGACITY �, . :-� � � . � �" C2rtdied copy is filec7 with the'coeinty buiMing inspec[ion 1&2-Family,Sq.Ft. — . �� .. NEAAEST- ,���� 1�� • ' departmentl � � � �`' � � • MuNi-family Sq.R. : _ . CROSS SI v ` '� � � Residential Swimming Pools atv�Eq OR -�^ �� C}ate��^.—ApPli�ant _._ �. .. _ ....�IRM NAME /JlifR :� G � � ���-CERTIFICYkFE OF EXEMPTION FRt1M`x1VOR10ERS'�� � � MAIL �/ � COIvIPENSATION INSU6ANCE < . Outlets:Rec—Light Sw. J Ifst 20 �0.DORESS�� �fj/`t`�f O�g7 � �• iThis"section neednot he-comWetetl�iF.ihe worJc;invotvetl�by the � F �permd is forone�hundred-.tlollarg�($.7Qq)or IessJ -. -. Total No. � pdditional -�-� C1TY. �. � � , yp� Tel.Na ��_ � �I�certify thafi'in the performance pf the�lvork foe wtuch_this��permit ... . PLAN BWECK _� ' APPLICANT -� ��.is�is5ued,J-Shalltn9f��erPPloy.any�,.pefs0{I i�=arry�rqanner,�.sp.as tD � '� � � �� � hecome subi�,to the,Wor�ers Sa� �.aws.�-...., Lighting Fixtures First 20�-��- ������� �� ' � AD�RESS- -- -�� � � �� �� � � �` � � �TotalNo._.(_ Adtlition9l__ � CITY � ������" � - TeI.No. NOTICE TO'APPUGAM�P Nltc aY � making r erhfic te Fixetl Appliances Not Over 1 HP ; „ PERMfi � .Exemptwn;y,oushouldbeco. subj tq�;he;Workers Cqm�ens on . ...Range_H�ater D.W. _ , , , aaPUCnNr (,J � �/!_ , . :,pmvisions of thQ�,Labo�God@;�,ypu mu5k for[hwdh cwnply;:wRh such Oven—Dryer_ W.M._ � ADDRESS� � Prgvisons ou;fhi��permit:sL�all 4e deemed,rewked. .,_ . �. ., Top� ---FA41..-.._.W.N.._'- . .... __.. . _ . ._ ...... . _ .__. � CITY��- � � � �Tel.No. � � - , �;�� �LiC-,ENSE�CQNT9ACTORS DECLAR.ATiON�.•.-- Hood— Fan _Other_ �l,here6y,affirm;,that I a�.4�eqsed u!�ef:prqv�siQns,o(.y�hapter 9 - Disp.� �—Room Air Gond-.� uCENSE oa_ „_.., . .. _._ . ...Class.. . (commenciqy�wiik�Sectipn 700Q�of Division 3 of the..Bpsiness and . - � REG.NUMBER Professions Code,and my license is in full force�and�effect.��� . . .-power�Apparatus&Large�Appfiances . .,.. DIS7a�CT No. , PROCE55ED Y � � .._ .. .._... .. _. ... . .._... - Size&Type HP,KW,KVA,onKVAR � - � License Number Lic.Class Up to 1 Incl. � � � FINAL��� � � � � ��� � -� ��� �:� U � `- •- .� � _Qver 1 to 10 IncL. DATE �2 v��(� d^ C6nhactor .. . ... ._... � Date .���.: � .. ... . _ . . ...... . VALDATION._.. . 0 ❑ Over 70 to 50 Incl�. � FINAL � . - I am exemR�under,$6c. .��- ' -� •- "' ��-�-- ---�ver 50�to-t001nc.. ._-.. �BV. ` � _.. . _. ._ ., W B.&P.C.for this reason � O��er 100 � . . .... . . .. . . .. . ._...._.._._... - Services.Swbtl.�MGG&Pznelboards. _. ..__.__ _ _ .. ,.. .. . ..._ _...... ..... ._ _.... ._... � �� � � � �� � � � '�a�: 0-200 Amp.Under 800 V Signature - � 201-'1000 Amp.Under�660 V � ��� ��� � �� - - � --"���- � � ���� -� �" ❑_ . .. ... . ...__. __. . .. _.. ...�-:. . � Over 1000 Amp.or Over 600 V .. . . .. . .. . . . . . .. �z�C'�+7�L�i Exemption for Reg.Maint.Elect. �� '��-� � ���-��- - ��` _ _. _ _ _. .. . _ _ - -.-„�; �m o e e �`43 SINGLE FAMILY� � .iemp..Power P.ofe&.Appurte�ances. ._.. __,_ . HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -{-�m"o"'1 ��j�j�"��� I hereby affirm that I am exempt from the Contractor's License Law for the following rea9on(Sedion 7031.5,Business and Professions Additional-Sign�Branoh�Circui4s �-��-- --- ��-- -�� -- -- � .�. . . � --� � .. . . r�x e� �� �," o � `Code): "�f Ip- I,as owner of the property,will tlo the work and the structure Misc.�-Conduits&�Conductors ��-� � � -� � � � � � - ��� � �- �� ����� �""���� � - 1 � is net intended or offered for salc(SecFion 7044,Business Other(See Complete Fee Schedule) , _. _. and rofessions Code). -������ CONSTRUCTION LENDING AGENCY � -� -- ������ --�-� � -�� � - � - � � - --� ��� � � I�here6y affirm that there is a construction lending�agency for the performance�of the work for which this permit is�issued(Sec.3097, � ���PERMIT"FEE -��"- ����� �` �-�(Sub-TotatY�� '�- �--- ���-�--"� - -�� � " ��- - -- - -- Civ..C.). � . '. . . . ..PCAN�CHECKMG PEE_ _ .. . ..... . ...._ . . _. . . . ..... . ... . . . . . .. ... . ...... Lenders Name � . . . ..PERMITJSSUING�FEE. ..- . . .. . . .. _ . .. . .__ ._ . ... ... . Lender's Address . � �^ ` � i certiry-that I have read this application and state that the above .TOTAL FEE .._......... . ... ._ .. . .,. �'� . _. ._. . information is correct.1 a ree to com � �� �� � g ply with all Gounty ordinances .and State laws regWating Electrical wiriry, antl hereby authorize . , __._._. .. _ .. . .._ _. . . . . .... ...__ ... . . ..... . .._ . ._. ... �. . _. _... ._. . representatives of this County.t enter upon the above-mentioned , prop .far� p ction purpo5 . � - - --�-SEE-REVERSE�FDR-E7(PLANATORV�lANGUAGE --- � - � --� -- � �.- � � � �f���� Signature o r-Rte Date � . ; � , � � _ . �� � � ���� ;„� ��� „ � �; t � � x �u � � � < 4 , ,, ^�� ,��_�. A, ,�z.�"< � . � �;�� :�_� Q:��� .,�� � � -� , ,�.0 'vy!_ ..� .,..... ,�aP'. , . .. . . .... �,k_. , .._._. . . ... .� ,,... . ��� .. . . � � � ....,.. .:...,e. ,,...._w .�.... .,, ,w.,.w,_. . 1..., .. .�.-.... ....�, . , � , . . ., � __._� .._� ~� �4PP.FCx>ALS ��-E_.. Ih!S�`E�� . _ _ -_.. . . OVAft�1ER�UII�D R QECI�FiA7iCilV .,; , � _.. "' _ .W.w. . S1aP.A 4RE" ` . -_ . 7�AhP PCIt/��PGLE` ° I hera.�y afFirm thyl�`dr�S'`�xcmp£'�Ibm#hn�-Cci fhadtAY"s License � a , .: „ . _�� .. . _ : � �. � - . -,�aN�for 31a�,fp�lo�,;s�2 re�l�(sec�ko77 7037��Bu&�e95"a�'�d � ROU CGNf3l3l7 � �....�. __�� .. . �to conssuanc.;#also rem.veseor ctwttiy wH�Gm�G4+u�S,a A'�it � .�MpE�SLAB`rVG VC i� Pnrfessrcr�C�cYs? 9nY af . .�._ ..... � mf, motrsh pr rep��7 any structure,Pria .� �<'�.,xa �_� VJif�NG '�� � .. ., _... , o �a�sryrieusratarnAnt Haat he fs�,lrcnr�i twrs�anria tke�ovrsrn,f+7s , . -s : .�,_ .---r.. ._€.. -. . at fn Cortf actor 9^LJcensG L'��v F�hapte<.«Yrommepcfn9 wrtit __ �_. .: . .� � _ . ... FGGCTt.IRES � .„. __. : r' , . ,� ;t�:�SechOn 7Qfl47'0��viSKin.:.�.�of fhe BusiFless an�+4YofesStons � ` .....� ; �--�. ; POYNEPo at)�'Ftb� I�ECS;._ _ ...... ,.._. _�� ,., ,-� ._..' : CodeJ a that.-tm is e�em.pt-M9rt?/�rirt1";ahtl the�basFs''tor.;,.tae � ,� � ._.. .._... UTI IFF'uO:�r10Ti fEIJ � ��. � .�-,--� � �„�2ppg�8hi�im�ArtyU'�����t 5.leCant to a cnviY��peh�: t —,— . . _ . � . . ., �. .,� . .� ....-. -.-; . ..,�. . pf not re'Ef?ar�troz Fu>x�!dolAars(S�af)D} ., . _ ..- �N�t _ }%�atva t+rs Fronf. ,;, . .�- � , " *.. �. �-� ❑'��as owr$r qf th�Prop ty�x�ll 90 ha+mrk,a+7d the� --_,__ " .. vo7CS ...__. _ � � ' , � '�*.�,83r.uC�Jr��sne�SeSd d,ar'o}fer d cr sale . .__ .i f � ,-, ; ,�r�.� ,:.. � �, � . , „��, � , q,`.Bqs+�&sS an�'frofessaon�"GodA The Conirevf4N'`s . ,� .� �.�Sec 7"J4 �r __.. -`... .._,._ ., J : ' L9cccasy taari�o'es rrot�f�Pty�to�r bPnfer`�of.pmperty idho*trvikis ,..� , . � � . i . ,. - C ��.._._ i., P . . . , �. � ...._.. --. . � oY'�rrav�roves tlr'e;uon r`kf�wtrt)Wlces suGh�''iv�.,rtn tl�risAF!'pllwftlE.ff � , ..'..._.. ..,.._....._.._._.. _.__.. . .__._._.. _ ..._..: . . ; -...� .. - . . . -. ._ . ,, . . : _ ��- ....._ � � ..... �� � that such rtnprifvqrn�nts ati��'not inier�rleif�a offered-for�sa(A:�If, ` y1 . . . ; .�, � � �� . s _.. _., . _ _. _ __.... .. ...... ._.. ,. , : �� .._ '�-. . �' _._ ,� ' howrver,2tie'S7'uddM9 or'itn}irkVeinent�is�-wM��tiviihin one year a(� . �, � _�_._. _.�_ . ... �..�,�, _-_—�r�--���- r,eaaTpPebon,tt�'awnrr 6urttf�a'fwdl hflYe the"b�1rtlP,.n ofbroJfng t4aat � . _...�._,..�,...� .W ...:..:...,., .o.��_..:..�, , ..,: '�. ; � �7ie Uid not�U'si17d or+m�irove�fnr+he pumdss af salel"r:� ) ,.. . . , , . . .. c,. � ., ,r , .,, o. .,. , . . _ . , �.U, ... . , ... . . , . . . . � . .. � ' � �.. 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