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HomeMy WebLinkAbout1187A ����ERS'COMPENSATIONDECtARATION 764663 �o,a� qpp��CATION FOR ELECTRICAL PERMIT � I her.�'i'oy offi�m Ihat I hove a cer�i(icate ot consent to self CE-806C � tnsu�e,o�a cert�Flco�e of Wo�ke�i Compensai�on I�sura�ce, COUNTY OF LOS ANGElES BUILDING AND SAFETY ar a certi(led copy thereof(Sec.3800,Lob.C.) P❑ollcy No. Comppny FOR APPLIGNT TO FLLl IN JOB -�Q Certiiled copy is hereby fumished. New Residenilal Bldgs.8 Pools EACH NO. FEE A��RE55 �l Crao K � -.L�• � Certified copy is filed wiih ihe counry building inspec• 7 8 2-Family,Sq.Fi. E — E IOCAIITY /An-j0 fj�'- lion deporlmenL � Mol�i-fomily Sq.N. — NEAREST � � Residential Swimming Poo1s CRO55 5T. pV�� •{� -r Date AppHcan� OWNER OR � FIRM NAME 1 CERIIF�CATE Of EXEMPTION FROM WORKERS' Ou�lets:Ret_lighr_Sw.' � " ' '��� � COMPENSATION INSURANCE . � ADDRE55 M �S A�D � Thls s�ctlon nMd not b�com t.t•d I�1h•work tnvolv�d b Firsl 20 ( P Y Total No. Add�tional CIT 1 Tel.No. 8(0 � th�p�rmit la for on�hundr�d dollars(5100)or I�t�.) I certify�hat in�he performance of the work for which this qppN�qN7K permit is issued,I shall no�employ any persan in ony monner . so as to become subject to the Work rs'Compensation lows. Lighting Fiafures First 20 A�DRE55 . Additional �— Tolol No. CITY � Tel.No. �°�e � � PP�'��^� t� Fixed Appliances Nm Over 1 HP pEpn�,ii NOTICE TO APPLICANT: If, ofler moking ihis C litimte of Ap���NT�L� rn Eaempfion, you should become su6�ect ro the Workeri Ronge_Heater_D.W._. Compnnsotion provisions of ihe lobor Code,you must/ar�h- Oven _Dryer —W.M.— ADDRESS'� re ,k � . ilh mmply lth such provisions o� ihi5 permit sholi be Top _FAU —�N.H._ CIiY Tel.No. deemed revoked. Hood _Fan _O�her_ � � �� d /�3 LICENSED CONTRACTORS DECLARATION uCENSe OR I hereby affirm thot I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER� Closs. (commencing with Sec�ion 7000)of Division 3 of the Business DISTRIR NO. PROCESSED BY p}„' ond Pro�essions Code,ond my litense is in full force ond effect. Power Apparatos 8 Lorge Appliantez , � Size B Type HP,KW,KVA,or KVAR � U licen5e Number Lic Closs Up to 1 Incl. FINAL � - Over I to 101nc1. DATE �2.,��,� V LIDATION O Contractor potc Over 10 to 50 Md. FINAI /\� ' W ❑ I am exempr under Sec. Over 50 to 100 Inc. BY �!�J� � ' B.BP.C.(or Ihis reoson Over 100 � ► Z Dale: � Services,Swbd.,MCC 8 Ponelboards - , 0-�00 Amp.Under 600 V . ��. Signature 201-1000 Amp.Under 600 V � � Over 1000 Amp.ar Over b00 V � . Exemplion for Reg.Maint,Elecf. ,e'�.�.� � 8,7�{ ��, SINGLE FAMIIY Temp.Power Pole 8 Appurlenances � � �� HOME OWNER-BUILDER�ECLARATION g�g�,,.��th One Branch Circuit �`� � � � �2 � I here6y affirm thot I am ezempt from the Controcror's License Additional Sign Bronch Circuiis ', � •.� � �,`L 5 Low for Ihe follawing reoson(Section 7031.5, Business and . �, Proiessions Code): ��. � _ ' � I,os owner af the property,will do the work ond the M;sa Conduits 8 Conductors . � • •� 1 1:2 5� strucWre is not intended or offered tor sale(Sedion Other(See Comple�e Fee Schedule�_ , ' D B.P 5�8 6 ' 7044,B�siness and Professions Code). CONSTRUCTION LENDING AGENCY � . 1 hereby affirm that there is a constroction lend�ng ogency(or �� � the performance of ihe work for which thit permit is issued PERMIT FEE (Sub-Tolal) � (Sec.3097,Civ.C.). ' � PLAN CHECKING FEE - - , '� � Lender's Nome ' � PERMIT ISSUING FEE - O ��. . lender's Address / I certfly thot I hove read this applfcotion ond siate fhot Ihe TOTAL FEE . / �� � above informa�ion is correcL I agree 10 comply wilh all Counfy . �. ordinonces ond Sla�e lows reguloting Electriml wiring,and . '� hereby ou�horize representatives of Ihis Covnty to enter upon , �. ihe a ve-menroned property(or inspecnon purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE 9—�.S"—r� Ignoture of Fer ivee �ole . . ._ ; , iR's'� O R CLARA ION ' WNER-BUILDE DE T . .. � - .,_ A^PFOVA:S � _DATE_� . -.SiGNATUFc . '_._._' ...__f .__ . . . .. .. . .. . . � � .. r ., � - TE1.1P.PO�VEP.PD.[, . ; --- --- - � • I hercby effirm�hcr 1 om e+xempt trom rhe Contrac!cr's . .. _ _ , . .. lice.ns_ la..• for tho following reason (Secfion 7031.5. �� . �� Uf+IDERSLAB IVORK-� _..- ----- -�-�- , ....: ' '.� � v Y Y __ .._. .. . . .___ ._ ftusiness ocd Frofesslorts Code):An Uf or tounf whlch _ _ ___. ..._ ' ' - � � , , requlres a pormit ic conztrutt alter,improve,demolish, ._--- ' �.'' �-_.. ROUGH CONDUtT .__ . , �,, .......,. ., . , .... .__ __ .. ._ ..---_. . ., �. . -�. � S - �or repols any sfrudure,'pAor to�rts issuanca, alzo re- _ .-� ..�'` `. -,. - �VJIF,ING .-'� -..�. .: ..•�.��T,�G � , .,... ! 9vlros fhe opp(Icanf fersach permlt to fl(e a slgnadsfate� � � � �.._. . FIXTURES '�-� � , . � menf thae he f;Ilceneed pursuaN to�bc provJsfcn:of fhe -- - - , - �j_�� r � - G�1�� � � . �Conlrc:!o�s Lfcenso Law(Chcplar9(commanUng wllh ,--.- . . ' ,. �..,. � ' � ' �� �'�� � -�� ���� Sedion 70CJ).ol DiWsion 3 0l thr-B�siness end Proie;- � � � - �___._ �'.FOWERi.UTHORIZED .. . . �. .__._ ___ _- _... � . . . . _�.. . � - � �� -- sions CodeJ or fhat hc is exempt therefrom ond ihe bnsis . U71lINC0.tJQTIFIED � � ' ' . .for }i:e�-oilo�od oxompNtn,�Any viololion ol SecHon ...__.__ __ .. .___.___ ... � FINA: . . . c-� ------ . �. . . . � �� �� .,_703i.5 by any app(icaM for a Fermi!subjerfs the appli- ; . _._,_ ___,_ . _ _ . , _ _._.. �nlv�on _t.orl � � �� � ccnf to u civff penoffy of not moro lhan /fvc hundred _ . . ... ._. . . ..__.._NOTES � ' � � - ----- - ... , , dollars(S.00).r..':. �. . . , ._ .. -; . , - . _-_ _..__._ _. . ... _ .. ._. . ' .., , ,. , . -. : i _ _.... ,... - - - �- will do the wark,and'�� _ . � � , v I,cz owner,of tho property � � ' � � „ihe sl�ud•vro is nct infendod or of.`ored for sale. � ,� „ :� . �� � � � �� �. � � ��•��(Soc..704-<,BusinauandProlossionsCode� 7heContrec �•� _-. � '_.' .. _._. ' � _. .._ ° �- � � '� '' . - . •.�. ... ����...� • dor's 17centcla�m daos no1 apply to an owner o�ptoperfy � . , � � , � .. � , � who 6ullds or�Improvas fhoreon, and who does such ... . . . . � .-�� � ..,. ..-: ;i�: .. ,, ,. , , :.. .. . .___'� . . . . . ' � ---- ' work hlmsnlf�rovldFd thnhsucb�lmprovemenfs ore nol .._ _._ . . . _. _ . . _ . .. .. . _ _ . .. .. � . � � � ���� ''� � � Irtfended ar affrred for sale.If.boweveq the bulldin�or . . __... __ _____._.. . . . , ' �-' " '�" '-" ' '' �' " ���' ' ' � vmprovemenf�e acfd wRF�n ono yeo.cf com,letion,Iho � � . � �� "�ownor-boilderwiflhovefheburdenofprovingfficfhedid � ' � ' I - � � ' ' ' not bulld or Improve/or ihu purpcso ol sofa) . ` . �' - . --.�.--._ ___._.': ..�' ' ,.�. . . . __..��am exempt under Sea . . . . . ---------_.. .._.. ... .. , . . . , . � ;... . .. ... � , . _- -- .....-----. . . .. . .--. . . . . . �. _.. _ ,...-._.. - __ � � -_....B.ZP_C..forthisrcason � ` ' . _ ... . . . _.; .._. „ . ,.. :, � . . i, - � - ---. . ... ._._.._ .. ._ . . �_ .. : _. �are- . .. _ . . , � ; . �. �. � � Owncr �� -_ _. �.. .. . . . . . , _. . . . �. -�\� . .. . .