HomeMy WebLinkAbout1811A .,� WORKERS'COMPENSATION DECLARATION ��� ,��81 APPLICATION FOR ELECTRICAL PERMIT �
�I hereby affirm that I have a certifiwte of consem ro self
i�sure,o�a ce�t�fimte of workers'Compensation�nsuron�e, C� E COUNTY OF LOS ANGElES BUILDING AND SAFETY
µt��f}fj�,Lp t o c.3800,Lob.C.)w � - (,,,��19'
�w rs.-�t� ��{��{.•/�yyry��}
�olicy No. ompanyw�-*-�� '�l''�1 � FOR AMLIGIR TO FILIiN . JOB 1 ����1���� y�
Certified copy is heraby furnished. New Residentiol Bldgs.8 J�p s, — s ADORE55 '1 Q4 C-.�Vi`I U JJ�+v�..
EACH NO. F E
� Certified topy is filed with tha county building inspeo 1&2-Family,$q.Ff. � 10CALITY
lion deporiment. - Mulfi-fomily$q.FL �NEAREST
O�c E��'''� Ele�r�G Residential Swimming Pools ��uST.
Date�v��ApplicaM OWNEROR � ,^�..,�'��
FlRM NAME r�7 ti r u..
CERTIFICATE OF EXEMPTION FROM WORKERS' Oudets:Rec�Light�5w. ��« /�� ^''_ �p�
COMPENSATION INSURANCE . � ADDRE55,L.1�I E.YTYI�. ��W
(This s�cflon n��d nof M compl�hd if fti�work Imolv�d by First 20 CITY Tal.Nor�t
fh�p�rmi�i�for on�h�ndr�d dollan(SI00)or In�J Tmal No. addiuonal C"f�—
I certify that in the performance of iha work for which this qpp�NGqNT�
permit is issued,�shall no�employ any person in any manner � � �
so as to bacome su6ject�o.the Workers`Compensation Laws. � ligh�ing Fixtures First 20 ADDRE55
Tmol No.� Additbnal
CITY Tel.No.
Da�e oppli[an� Fixed Applionces Nof Over 1 HP pERM�T �y� C •
NOTICE TO APPLICANT: If, after making ihis Certifiwte of APPLICANT � �1� G ((�.
Exemption, yoU should become suhjecf �o the WOrkeri Range_Healar_D.W._
Compensotion provisions of the labor Code,you muaf forth- Oven _Oryer _W.M.— ADDRESS 5�-C �.
with comply with such�rovisions or this permit sholl be Top _FAU —W.H._ [�'�ta�ir�d� —Ztp I
deemed revoked. CITY �` y� � Tel.No
LICENSED CONTRACTORS QECLARATIQN Hood _Fan _Othar_
Disp. �Room Air Cond. — �f�N�� 4.� 24.2 Closz.G 1Q
I hereby aNirm that I om licensed�onder poviaions of Chopfer9 REG.NUMBER
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. P ESSED BY.
and Profcssions Code,and nmy license is in full force and effed. Power Appamfus&Lprge Applipnces �
4�SG4Z C'��O 5iza 8 Type HP,KW,KVA,or KVAR Q
�ice�ae Number Lia Closs Up to 1 In[I. � F�Npd V
�-`-� �� � �--�L`�83 Over 1 l0 10 Incl. DATE �/Q� VALIDATION O
Coniroctor Date Over 10 to 50 Incl, -
❑ FINAL
I am exempf�nder Sec. Over 50 to 100 Inc. BY �
B.&P.C.for fhis reason Over 100 N
Servicea,Swbd.,MCC$Panelboards � , Z
Date: 0-�q0 Amp.Under 5W V
Signature 201-lODO Amp.Undar 6W V �1 �'i.1 A
� Over 1000 Amp.or Over 600 V . � � .
Exempiion for Reg.Moint.Elect. '�F• • •2
SINGLE FAMILY Tamp.Power Pole 8 Appurtenances I • •J,�i.� �
HOME OWNER-BUILDER DECLARATION Sign with One 8ranch Circuit • • �:J ��' � c2,
I hereby affirm thot I am exampt from ihe Confroctor's litensa AdditionaF Sign Bronth Circuits •
Law for the following reason(Section 7031.5, Business and �9,�%_c�3
Professions Code):
❑ I,as owner of ihe ro ert Misc.Conduits 6 Condudort
p p y,will do ihe work and tha Other Sae Com lete Fee Schedule_
strutture is not imended a�offered for saie(Secfian � P 1 ►
7044,Business and Professions Code). �
, CONSTRUCTION IEN�IN6 AGENCV
I hereby offirm�hat�here is o construction lending agency for
� the performante of the wo�k for whith this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097,Civ.C.).
� PLAN CHKKING FEE .
. Lender's Name . �O
PERMIT ISSUING FEE
Lender's Address �
I certify ihot I have read this application and state that the TOTAL FEE .��
above informotion is wrrect.I agree to comply with all Counry .
ordinonces and State lows regulnting Elettrical wiring,ond
hereby authorize rapresenlafives of this Coonty to enter upon .
the above-mentioned properry for inspection purposes. � �E REVERSE FOR EXPLANATORY IANGUACE
!�ina.� 7�� 8 2s-83
'gno�ure of Permitlee Dote
�
� � � . � ��.APPROVAL$ DATE ��` . � •• y . . . � . . :.,,. OWNER.BUILDEK DECLARATION . ..
SIGNATURE
7EMP.P01NER iOLE � �� q I hareby affirm Ihat I om exempt from �he Conbacbr's
� � � � ' � Licenss Low for the following reason (SecTlon 7031.5.
UNDERSLAB WORK - � Businsss ond Prolaasbna Code):Any dty or coumy whlch
ROUGH CONDI�T , ; roqulros d psnr�lt tq conslruct,alfer,Improve,damollsh,
� � � � , or npalr any shuNurs,prlor fd!Is Issuance, olso re-
� � � WIRING , .- ' , qulnz th�appllwnl for su�lf p�rmit to(l!e a s7gned srofe-
� ��� ' ' F��� � msm lhat h�Ia Ile�ns�d punuom/o the provfslons of the
� �`'... . ,.i_. � . Conffoe�or's Llcsna�Law(Chapisr 9(wmmenUng,wlth
POWER AU7HORIZED S�cHon 7000)o/Divfalon 3 of�he Buslnasa and.Paofos�
sipns Cod!)or ihoi he 7s exempt�Fere/rom and fhe bosis
UTILITY CO.NOTIPIED ior ths aUaged exampfion. Any vlolofion ol SecNon
- FINAI L' � � 703J.3 6y any opppean!for a permlf su6JeNa ths appli-
nfe�on ronf cnM to a cfvtl penalfy of not more�han livs hundred
� NOTES dollon($300).:
. . . � , C]I,as ownar of tha property wlll do the work,and
the siructure is not iniended or offend for sale.
� • „ . � � . (Sec.7044,6us7nass and Professlons Coda: The Conlroc-
for's Llcrnse Low does nof apply to an ownor o/property
� ' � ' ' ' wBo bWfds or Improves}heroon, ond who does sueb
' work hlma�ltprovldod�bof sueh lmprovemente ore not
� � � �� �� �� - � Intendod or oHered for eale.N,bowever,tbe bullding or
� improvemenl Is aold wlfhfn one year of rnmpiatron,the
. � ownsrbuilder wtll have�he bvrden of proving fhot he dld
' � -no)bulld w Improve for�h�puepos;of sale.J
-.I pm exetnpt under Sec ,
B&P.C.for this nason �
Dote
Owner
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