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Home My WebLink About1810A WORKERS'COMPENSATION DECIARATION - ��.� ,0,81 ppp��CATION FOR ELECTRICAL PERMIT � I hereby affirm that I have a certificate of conseM to self �'� . i�sure,o�a�e�rifi ate f worke�s'Compensanon�nsuronce, � COUNTY OP LOS ANGELES BUILDING AND SAFETY ��or certi{�'pd y�.�h(glr f �}C(,,3800•,'C_ab_.LC.)/�,,,,,�� c��'�v�pp�y��T NT f C.1'��eQ. FOR IVPLIGNT f0 FI1L�IN� � JOB �/� /^��(1� �, � �`'��.,�� Ce��ified copy is hereby furnlahed. New Residential Bldgs.&Pools EACH NO. FEE AD�RE55)(LyJ�•l��Y ,�/�{A/� 1-&2-famil Ft. s� — S tOCALITY Q n.� dCertified mpy�is filed with the county building inspec-, Y•SQ� tion deporfinent. Multi-fomily Sq.Ft. — 'NEAREST � '�,.J�,J—�',� �1�-� E��r� Residential Swimming Pools CRO555T. Date Applicant OWNER OR /� / FIRM NAME C�I ^',�,�+� D CERTIFICAOM7ENSATIONI�INSU AN EORKERS' Ouflefs:Rec�Light�5w/ DDRE55��) ��'�TT 1.JT� � F�.Sf so 3 (This s«fien nwd not b�complN�d N 1h�wark involv�d by � Tolal No. Additional � CITV Tel.N . the p�rmN fs fo�on�hundnd dollara(;100)or bu.) I cartify that in ihe performance of iha work for whlch this �ppNj�qM permif is iss�ed,I shall no1 employ any perzon in any manner so as to betome subject�o ihe Workers'Gompenaafion Laws. Lighting Fixtures First 20 ADDRESS iotal No.� Addifional Da�e opplica�l CITY Tel.No. � Fixed Applionces Nol Ovar 1 HP PERMIT �,� � "� NOTICE TO APP�ICANT: If, after making this Certifimta of . APPLKANT 1'� W-y' • Exemption, you should become subjact fo the Workers' Ranqe_Heater_D.W._ Compensation provisions of the Lobor Code,you mos�forth- Oven —Dryer _W.M._ . ADDRE55",S —G U �- wi�h comply with such provisions or this permit shall be 7op —FAU _W.H.� deemed revoked. � Hood _Fan _Other_ CITY �v `�� Tel.N 1�8 IICENSED CONTRACTORS DECLARATION LiCENSE OR �/��n I hereby affirm thot I om litensad under provisions of Chapfer 9 Dizp. —Room Air Cond. — REG.NUMBER �� y�'(� Clau.G (commencing with Secfio�7000)of Division 3 of fhe 8usinesa power Apparotus 8 Large Applionces DISTRICT NO. + PR ESSED BV. r and Profeasions Code,and my licensa is in full force and effect. // d ^ (�J�,�7 /� $ize 8 Type HP,KW,�KVA,or KVAR- �( 0 License Number �T'V�,`Lic.Cloas`I O Up to 1 Incl. FINAL V Coniroctor�I ITG ��-• Dote�� Over 1 to 101nc1. DATE / _�O^ � yp��DAT10N � ❑ Over 10 to 50 Incl, FINAL ~ I om exempt under Sec. Over 50 to 100 Inc. BY � B.BP.C.for this reason � Over 100 y . Services,Swbd.,MCC 8 Panelboards ► _ DO1e" 0-200 Amp.Under 600 V $ignafure 2(Il-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 6W V � Exemption for Reg.Nwint.Eled. c_.t ` f _ a SINGIE FAMILV Temp.Power Pole 8 Appurtenances HOME OWNER-BUILDER DECIARATION 5ign with One Bmnch Circuit �• • • • •i I hereby affirm tha�I am exempt from the Controttor's license Additional Sign Branth Circuits Law for the following reoson(Section 7031.5, Business and � � �µ�q j rofessions Code): �. . • , � Mix.Conduits&Conductors z x I,os owner o4 the propeny,will do the work ond ihe �' 'y '.`�:c structure is no�infended or offered for wie (Section Other(See Complete Fee Schedule)_ , - 7044,Business and Professions CodeJ. U��Q�'^ s�� CONSTRUCTION LENDING AGENCY. . I hereby affirm thal there is a consiruction lending ogenty for . the performonce of the work for which ihis permi�is iuued PERMIT FEE (Sub-Tofol) - (Sec.3097,Civ.C.). � PIAN CHECKING FEE _ Lender's Name � PERMIT ISSUING FEE �Q Lender i Address I certify thpf I have read lhis applicotion and state thot iha TOTAL FEE � . above informofion is correct.1 agree to wmply wi�h all Caunry � ordinonces and$tate laws regulating Elechical wiring,and . here6y authoriza rep esentatives of fhis Counfy to enter upon � rhe bove-mention d roperty for inspec�ion purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE � F7—Z.J`�J Signplure o Permittee pote 9 AaPROVA�s DATe _ `�'�'- QWNER-BUILDER DEC4ARATION �. }` SIGNATURE � � � �:TEMV.�POWER PDLE � � - I hereby affirm fhot I am exempt from ihe Controclor's License Law for the following reason (Sectlon 703i,5, UNDERSLAB WORK . . Bualneas and Professlons Code):Any clty or county wh�ch � ROUGH C�ONDUIT nqu7rea a petmat to eonslruN,altar,Improqe,demolish, � �� " � or rop61r ony structuro,prfor fo i�a�lsauonee, also re- y � . WIRMG ,,,��— �— � qWros tha appllepM for such permtt to flle a slgned stofe- FIkTURES m�n�1ha1 h�!s lle�na�d punuant lo fhe provls�ons of tha �`",�, � � . , � Confrallor's llnns�Law(Cboptar 9(commenNng wilh POWER AUTHORIZED Secfion 7000)01 Olvlsion 3 of�he 8usinesz and Profas- slons Cod�}or thai ha 7s exempt fherefrom and tha 6asis UTILITY CO.NOTIHED - -for The allagad exempNon. Any vlolotlon ol Sectfon F�� Gnlar an ronf 703I.5 by any appllrnnf for a permlf subjeela tha opph- cant fo a Nvlf panalfy of rtof more�han iive hundred � NOTES � � dollara(.$500).: , , � � ❑1,os owner of the property wil)do tha work,and � tha shucturo fa not iMended w offered for sale. - � - ` �� , ,. .. � : . � � (S�c.704{,Burinoss and Professlona Codr. ibe Cantroc� � � tor's Llcrose!aw do�e no�apply to an owner o/properry ' � � � � ` � � �' � who 6uilds or improves thereon, and who doet ruch work h�mself prov7dod IFot suoh Improvemen}s ore not � � � � � � � ��Infanded or o/iered(w sale.If,bowever,�ha bu11ding or improvement Is sold within one year ef completlon,fhs ' . � � � ownsr-6ullder wlll have fhe burden ol provfng thot he did �nof bulld or Improvs Ior;iMb pu1'pose of sole.) �� „ I am exempt under Sec., � , B 8 P.C.for this reason Date Owner , ._ . . _ � .� ,� , �� . .