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HomeMy WebLinkAbout1813A (10) ., �� WORKERS'COMPENSATION DECLARATION � � ��6� ����87 APPLI'CAl',���lu F�R EL�ECTRI�r�kL P�RM�T ��� � � `j� � I hereby afF'rm ihat I haue cerfificote of consent to sel4-� CE80sG � . � nsme,or a tertif caYe of hA/orkers'CAmpensation lnsurance,' ��,{�,� COUNTY OF LOS ANGELES BUILDING AND SAFETY L� �o `�cB JSf�}'q5��-�q�p) th f .38FD0`,'La�b�,yC.) j� � � '��q-�{� � � � � ��".�j ""��� �/C.J7 .. , FOK APPUCANT 10 Fltl�l .. . ... JDB /`��,.,(����,, � . ol cy o C mPany �F-Y�{�� .N. . .+ G . .�v- o L1 Ce 1 f ed copy 5 hereby fVrnished . New Residential BIdgS.& o EACH NO.. . FEE . ADDRESS.{� Jr l..I�(,.7�TGl�Ir:/( �1�V' � g� . — g LOCALITY�Q t�(�(��- d Certified copy is filed w�fh the county bmldm��inspec-^ �-�2-Kam ly,Sq:Ft _ tion departmehr .- � � � � R!iulfi-famrly Sq.IFt �� NEARESY � ��17f��.0'�.Z �C�.l� ���1 Resident'al5wimmingPools�.� " � � CRO555T ' . . . Date�Applicanf . .. � . OWNEROR: : 1 Q'^�. G�._ / �- FIRH1 NAME ) . Y UI �� CERTIFICATE OF E7(EMPTION FR4�M WORKERS' �.- Oufletsi Ret�Li�ht�$w.iL._ �''�� ,�1 - 'L M � " � � COMPENSATION INSURANCE �� � . HDDRESS G�.Q f. �a �'r �F�vl/ - First 2b �� h___ . ��,� � (ihis settion nee'd nof be�compF�tvd�ii Tha work�'involved by Total No. CITV TeL � iho�pormi/is forone�kundred dollan{;100)-or less:) - Additional •�4{���� 1<eri'rf fkar in�he, erformance�bf ihe work�for.which this . PlANCNECK° �_ ..,, - . V P .:. � ;. �. APPL1CANi �permit-is issved,�shoFl ndt employ any pBrson io ony manner � �� - � �.' . � . so as to�become�5�6ject to the-Wo�keYs'Gamperrsdtion.taws. � ��ghting Fixtures First 20 - ADDRESS- �� -� . � � . . ... .. . . .. Addirionaf � . �.� - . . . . ... .. � � � - � To�al No.� . .. .. CITY. - . . . .Tel.No. Date Applicont .-��-�' � Fixed Applionces�Not Over 1 HP ��PERMIT L � ROTICE TO APPIICANT:�If, after moking th's CerYificate of � . �. .� qppucAM �����,C.�.-�'�.�i���(i � Exempiion, you should�became-sub�ecr to the;Workers' $gnge_HacYter_D:W._ - _ " .� � /�� , �Compensatlan provi5ions-of rhe Laboc Cade,ya6.musl�forth- �Oven��Dryer _W.M.— � � � ADDRESS�7�j25—�' �U�..�.� � �,�-�/C�- with comply wi�h suth provis ons or th s permi!shall�be Top _.FAJI; ,—W.H.._.-- � � . � deemed revoked.. ��.. , . .� .. Hood� �_ .. . .. .CITY ��.�.�/�X�1���- Tel.N�� �.��, _Fan. Other— - IICENSED CONTRACTORS'DECLARATI�N . � �� � � � - � IICENSE OR /��{ .���(/� 1 he�eby affirm ihof I amlicensed under provisions o{.Chapter 9 Dispc —Room A'r Cond,�— �REG.�NUMBER.-4^([, -�4ir►G. Class:G:��. � �co ,g w tionJ00D)af Division 3 ofi ihe Bus ness. - � � DISTRICT NO:� PR SSED BV ond Professions Code and,my I cense rs i full force�ond effecL� Power Appamtw.8.L rge Appliances . . , . � - � menyn Se S¢e'8 Type NP,KW,KVA,ar KVAR . (� �License Number • �r-��`��Lic.Class�V���. ..' . . . . FfNl�L... ... .. . . . . . .V .. . i .�, .g Up-to 1 Ind�. DATE CC- Contrac�or�����'�Date v���Q-"� .. . .. Over 1�0 10 Incl.. .� . . ...1�.:��t �� . . . VALIDATION . �Q _. � Over 70 fo 50 lod: FINAL ~ ❑ I am exempt under Sea; � - � OverSO to 100 Inc. , . BY � � ; _ � 4 � 8.6P.C.for this reason � - . � Oyei 100 . . � Z � �-Date: � - - Seivices,Swbd,MCC 8 Panel6oards : - � ��� � , � � - � . � � � �0-2W Amp.Under 600 V� , - - , � Signature � � � 201-1000 Amp.On[ler 6W V � � � - � � �. � - . - . � . � � .. Over-'1000 AmP,or.Over 600 V ''`��} ��i.`�`1� � ❑ .Exemp�ioo ior Reg.�MoinL Eleci. _ �. � �� . � . - .. � . - . _ . � . . -�� }��o c.s � e`� . SINGLE FAMILY � � Temp..Power Pole.&Appurtenances � HOME OWNER-BUILDER DECLARATIOIV . � Sign-with One Bronch C�cuif` . � � � � A L�:�� I hereby affirm ihat I am exempt from�he Contractor's License kdditi�onal Sign Bran<h Ciauifs � �law for the following reason j5ecfion 703}.5, 8usiness and . . . � � �� . -� � � � �! n .��- Professions Code): � � � � . - �- � . � � � � � - "� ' �❑' Misc.-Conduiis&Cond�ctors� � � I,os owner of the�pr�perty,will do,ihe work and rhe ' � � L�.�i !'"�J � strucfure not intend d or offered for sale (Section Pther(See Complete Fee Schedule)— � , � � � 7044,Business ond Professions CodeJ. , � , � � . . � � � CONSTRUCTIONLENDINGAGEIJCY � � - � -- - � �� - � �- . .. � � I hereby affirm that there is a mnstruction lending agency for . - � ihe performance of the work far which ihis permit is.issued PERMIT FEE -� � (Sub-Td�ol�- � � � -� -: -- ���� - �. . �Sec.3097,Civ.C.). � . - ' � � . . . . ' � � � � ... . � . . . � . �PLANGHECKINGfEE� ... .' ... , ... . . . . . ..� _ ... . �� � Lender's Name� -. . . � . . . . . . . �� � . . �h: .. . . . .. . ._ . � . � PERMI7ASSUING FEE . . Q� � _ ., _ Lender's Addreds � � � - � � . � � � � � - � . � . - I cerrify thot I have read this appliwtion ond�sinte�ihot 1he ?OTA4.FEE - � - above inforrnahon is coirec7.I ogree to comply with all`County � - � - . � , . � . � . . . - � ordinonces and Stote lawaregulpting-Electrical wring,and � ., . „ � ., � . i hereby authorize represenratives of rh�s County ro e�fer_upon � � � . � � .. � � � � - � - - -- � -� � . � � the bove-meniioned property for inspecfion purppses. - - � � �- - _ � � �SEE REVERSE�FOR EXPLqNATORY LANGUAGE ,�� . . [S��� ' � g-��3 _ _ . . _ Signature af Peimiftee � �Dafe - � �� � , . �� . � . q : � r ., _. . , � _ . , ::�t ` �� � �1: ; � � � ��. , .' .. ` �� �pYJN,ER-BUIC6�R DEEUIRATI�IN-��'�' � . .. . _ .-A7PROVR65 DATE �;"SIGNAFURE ., . . ' . . . ��� � �. � .iTEMP.PdWER 6QLE I hereby affirm thpt I am exempt from ihe Contrador's � �License�law for fihe following�reason�(Secfion 703L.$, - �, � . , - . . _..�_ � � _:•. � . � ' - - UNDEkSLABWORK �� . .� ... �- -� . � .. �- � - -�� . BusinassandProfesslonsCode):ArtyNtyorcountywhfch � � ��ROlJG1iCOAIDWIT � � � -� - � � � � � � � g��', rr6qUh^etapermifittaconsfrucf,aMer iigrprg'v,e,de,raiolish,� ��or repai��any sfr�dYure,prlOr Vo��ils lssuOnte, olso re- .� ... � ..WIRING .-... . . - � � qufrestheopplicantforwthpeemlt�afilmasignedstate- . ., , - - . ment thaf Ra�ls Ileansod pursuant�tolhe provisions of��the •` :. ' ,Pik7URES.` . . ,�. ` . :� �., ' .. � .J�.CoMrdctor"s Lie9hse.,law C6o ter-9(r,ommencin4.w�th r . . _ F P � � '� POWER AUTHORI7FD - � ��- - Sactioa 7C00.�oi pivision$of�the Business'.and Prpfes- � . sions CodeJ or fhat�he Is exemµt fherefrom and the 6asis �� - � --� - � UTILITY CO.NOTIFIED-�� � �- � -� -for 1he tlflsged�exemption. Any vlobtlon..of 5ecfton . :� . � . � �n:� '_'c7� -'� .. . , ' .� .-J0.3i�.5:by anY appliarnt for a permit�subleds the appli- . ... - - - - FlNA�� �� � ���'Gnter nn.�t�n.� . '� � cant lo a 4iV1F pene(fy oi not more thart five handred .� - . -.- � . - . .-NOTES� � � , �. � . .� � � -dollan($500).: ` �� � rhe.work,and , � � C��.1,os nwner of the property:wifl dp, _ � .', { � - '� ��-� �� �� ` '�-��� - � ' � � -.�-ihe siruatU[e isnot int�nded.or offered for sale. ��� ., � , � . . . . � .f�See.70M,Buslness dqd Prblesslons Code:�.The Con�rat- � ,�. _ ,, . . .... . � , .-. �:-= . ^'�. . , '�.:. . � . . .��` � ..' tor's Llcense Law does�.noi apply to an owrter of�propeeiy _.. i . ... . ... .___._. ' `` . -- . .. wha lwitds or irrmproves�-Fhereon, and who does such . ��.' . �� . ,, ..-, .: .- . ` . � . � ���"y �� �-� :� .,� �- -- � �wbrk Fimspffp rovidad/h6l Buth�imp�ovements are not '. :-;_^ � _:'. _ . :,�: � :. . .. .. � . �.�'� . . ..�.-Fnianded or offered(or sole:li,.howeven the`buiiding.or ���" ' , ,,. , . � � Irhprovement/s sord wlihln one year of cor*�plpfion,the � �� " �°`ownervbuifder wiil have the 6urden of proving tfiot fie d1d - �, .�.._,., . . - . , �' . . . ,. � ��__._ � . . � � . . . ...; ..�. �.�� . . . ._- .-�� nWsbuild o�fmprove.:fo�'1be.putpq`se of safe.) � ' s,., -�,.-:.. . .. . . � � . ._ � � .. ... �:; . . . ... .�.,,,�am isxar�!Vnder Sac. � . . . . _.. . e&P.C.for thi' . . . , . . ,. .. . . .... .. .��...: . - .. s reason � . . . . . � . . . � . . .. . j , . _ � . . , ..,�.. _ � - . ' . . . ... .. . ... � �,.. . . _ . ... . . ... . . . Date� . .. ' . . , . �..� _�_.. . .. . ; Ow�er - . ... .. . . . . . . _.... .. . . . . . -. . .._.. . . .. .. � _ . . - . . � '� ,�._�F�'-.,�; . . . :� �.,.�,. . , . ,_, , .. ,., , . . . . , .. . . . . . . . . � . .{. . � . . � - . � . � � . �- . . :���, . . . � . _. _