HomeMy WebLinkAbout0916A — --- -... . . __.._. . _. _ ._ -- -- -
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WORKERS'COT4PENSATION'DECGARATICSN�-� 76Ab63 �ppL��ATIdN FO�i��J��6��1�� r4 � T
� CE-806G(2�$0) � �
. . . . . , �.. ,..._._ _. . . . . . . .
�- I hereby aFfirm Yhac I have a certificate of consent to setf COUNTYOF�LOS�ANfG�LE�`�-. "^�' BUILDINGANDSAFETY
insure.or a certificate of Workers'Compensation Insurance,or �
' a certified�copy�thereof(Sec.3800,Lah.C.) - - -�-�••
, ._ ... ..... _..._.,._..._.. -., ,„.__...,Y..�.:.: ... �� .<..- ..,.,�.w .� ..r .....a+a..a.a
. � � ' � � FOR APPLICANT TO FILL Ifk Jpg '
. Policy No. Company - EACH NO. FEE ADDRESS � { LIA £
... . .. - _ .. . New Residential Bidgs.&�Pools
' � ❑ Certified copy is hereby furnished. 1&2-Pamily,Sq.Ft. � � — g LOCAIITv D�e „
Multi-family Sp.Ft. — NEARES
❑ Cer[ified copy is filed w�ith the county buifding inspection � CROSS ST �� g, rM![.
Re idential Swimming Pools
�department. OWNEF OR +�
L�` . . � �,.�' .,�%' �' FIRM NAME � JA ��T'
\Date Applicant Outlets:Rec.,_Light_Sw.� MA�� f
� � � First 20 P.ODRE55 ,F'�S �C7'"OJ°�s
CERTIFICATE OF EXENIfS`I'C673`Ff201Vf'WY)R`f��T2S'� ��-� 7otal No. Additional CITY Tel No.
COhfPENSA7'i0V iNSURANCE�"� ����'�� � }
� PLAN CHECK �-
(This sec6on need not be completed if the work involved APPL�CANT _ V
by the permit is fot one hundred dollazs ($100) or less) � Lighting Fixtures First 20 qooftes5 �
- � Additional
I certifY that in the performance of the work for wliich this I F xed ApplianCes Not Over 1 HP CITV Tel No. �
permit is issued,I shall not employ any person in any manner PEFMIT ` � W
so as to become subject to the Workers'Compen�tion La�vs. Range—Heater_D.W._ APPLICANT x�/!/�5�'f �f-�fffC��� a
t ��;�` `._�j � � Oven ,_.,Dryer_W.M._ ADDRE55 � ,�� ^�.��, N
Datz�({ LV Top _FAU ._W.H.._ Z
Applicant CITV Tel No. �+.'f l��I/
Hood—Fan _Other_ ['• �5' J
NOTiCE-TO�.4PPL"ICANY:�I#,af4er makirig fYus Ceiti'�''icete of� pisp. _Room Air Cond._ LICENSE OR
ExemQtion, you should 6ecome subjec[ to the Workers' FEG.NUMBER Ciass '
Compensation provisions of the Labur Code,you iriust forth- Power Apparatus&Large ApplianCes DISTRIC7 NO. PROC SSED BY
with comply with such provisions or this permit shalt he Size&Type HP,KW,KVA,or KVAR !��,
deemed revoked: v�
, Up to 1 Incl. FINAL
Over 1 xo t 0 1ncL DATE VALI DATION
LICENSETJ�COx7'I'RA�'S'O1�5�'�'�.'��'k;4fiY0'���"���'�`��-�� Over 70 to 50 Incl. �� ��
�here6y affirm that I am Licensed under procisions of Chapter Over 50 to 100 Ine. BY AL �7
% 9 (commencing�vith Section 7000)of Division 3 of the Rusi- Over 100 �
ness�and Professions Code,and my ticense is in full force and
effect. / Services
License�lumber i�`��.Class �~b� 0.200 Amp.Under 600 V
^'� 201-7000 Amp.Under 600 V
�`Contracto^ ate � G�'— Over 1000 Amp.or Over 600 V�
,
HOML•OWNER-BL'[L�ER"DECL�RReCTfON��"���������"� Temp.Power Pole&Appurtenances -O 9 i,�i f` �
I hereby affirm ihat [ am exempt�from the Contractor's Sign with One Branch Circuit '{'z o o��S,F 't}
License Law for the following reason (Section 7031.5,Busi- Additional Sign Brench Circuit5
ness and Pr�tessions Code):
Misc.Canduits&ConduCtors L.a o c c e j
� I, as owner of the property,will do the work and the Other(5ee Complete Fee Schedule)—
structure is not intended or offered for sale,(Section ( � °l':;.b n
7044,Busiriessand'Profes'sions�Code). �
CONSYRUCTi(SN lIiNY>117G�AGENCY���� � =c:.:'v c—�
I hereby affirm that there is a construction�lendin@ agency � p�`
for the performance of the work for w�hich this permit is pERMIT FEE (Sub-Total) �; 'u � �'�'?�b �
issued($ec.3097.Cic..C.).
Lender's Name � PLAfV CHECKING FEE IOne-Fourth Permit Fee)
Lender's Address pERMIT ISSUING FEE � j,�'�(G
I certif}•tha[ I have read[his application�and state that the TOTAL FEE � �j
above information is correct.I agree to comply�wuh all Connty . �� " '--'� '�� � . - � � - � - -
,.. . .. _ ... _ ..._.. . . ._. ._ ..
. . . . . . ... . .
ordinances and State la���s regulating E]ectricaL wiring, and �
hereby authorize representatives of this County to enter upon -
the above-me t�ioned property r mspection purposes. � SEE�REVERSE POR EXPLAN.ATORY LAtiIGCIAGE ��� - � �
��.
� � �� -�=`3��C
Signatur f Yermittee Date
� • ....-...._......, �... ..., .
, < . , _ ONIiefER-BLJHLDER FJECL�R4TI�N
.. .. ..., .-. .. � . . ... i iee -ff I� t I t f tl �' t •.
-APVFiO'JALS � �����DATF. � WSPECTOR'S LiC2�sebI:acvEfe itne fclnwirtg rezsorn/Section�7031.5�
' . '. . ._ .._ .. . SIGNATURE Bug�necs and e'rofessroys Cade/: _Any city or c�uney
J �� � � -I TEi✓P.POWER Ppl� � � � whiCh requires a p2r?nir fo consxrurt, a;rer, impreve,
i
� " .. ` � ... .... ..... . . _ ..._.. .. .. ., em l Y e ' i 'c' c2
' � - � - - �UNDERSLA�WORI<' � ' � � � � o p¢r any arruc�i.rP,p�i'ta_tS e5..4�Gn .
_._
- ' ' "" - ROUGH CONDUIT- � S[e'oQdeq�atenlPntlfhn[et1he r[S�11'C�'tSPd (1ui'5�J.4J7(IOrt'he
f � � `
� " �
�. 1�
� � �� - ' . Wif�ING� � - � � � ' provisiotts of�the C2n;raete;'s License.7,nw/Cha�ter 4
� -
1 /eomrr.ettemg+,vi:h Secr.'on 70D�?/ cf Divasiwa 3 of 3Ae
. . � .. FIX�TuaEs �. � _ . �--- -- --'�"...... � � Birsiness and Professio��s Code/ c; •fi�tt he is exe;npt
. -. . .. , — therefrom a7d�the�s=''s for aiee telleged exemp?icn.Any
. PO W E R AUTH O R 17_E O viaiaticr of�SecC:ar. 70P1..i by¢rey appiiccnt for a Permi:
UTILiTY CO.NO7fFIED d'u�jects 5he eppTican.t:n n crvi2 per.ulty oJnnr more!nen
• � �� -. - - �five hUndred�o:lars(S500J.: -
' � . _ _ ._ Fwa� , � r('•r�ede� �ea �%��..� �,. - -... � . . . . , ._ ri f,as o�i�ner uf the p�opert��wil'do!hr work,ar.d
' - . � - � �the shucture is oot intended or ofSered for sale.
- NOTES . . . .
` -� - .. � . ' .. . � '" lSer. 7Q44. B�sines_and P�ejesaio.s Cade: The Co,n�
� � trac?rtrlr License Law dces not app7y so an owner of
-- � — . -^— _ , , , ., , pr�perry wno bvi7ds or improues thereon,anG xxho does
� � � . � ' ' ' - �" � � � � �:,uth-,wurk�h;mself j�roc�ided that sucls improvements
� - . . -' . , . . � —"� -. . ._-...-ere n�: inten.ded or offered for sa7e.�ij, howe.ir, the
� - -. _ .. - .. , ouefding or improvement,is soltl witl�aa on� year vj
.�� , • � . �-. � �, . -. —.....,,,co;npletion, the or�ner-builder�wrll hm�s the 5u�der
. . .. . . "." .- . . -. � ��:of pras�fn,a ihat he drd reot bsiid or im.prove for th2
.�: �. . .. � � . . � . . . _ ; �.,. . ..... �.. . .... ... ... :..:P'-rpose of safe.j .. � ,
., ,. ..... . , -....
. , f� ., . .. . .
' _ -_—"___- • �
. . . . - - _ ' , '__ ....�_.--^---- I 2ri2�XE131'�Y�YS(12Y�QC__�_.._____..___,___.
-- -- ' — - -- �&P.C.for tlFis reason ---.—_
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,_. . _ .._ _._ .__.,..,_. _._. - .
-- -- - — � --�---- �wne� �
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