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HomeMy WebLinkAbout1809A (10) �1'ORKERS'C037P�VSATIO\�ECL.4RATI01� � 76A663 - - -'�""^" . , � - �- -. . CE806-G12-80� .. APPLICATIC�� �OR �����T1�1�Ij►C���P��T" .w.. . �j [ herebv affirm tha� i ha}e a�certificate o:consent to self � � COUNTY OF L�S%CN-G'�LES��'���� ���'�� ��������� ��'�RBUIL�ING��AND��SA�ETY- - � �1 insure,or a certificate of Wo kers'Compensation Insurance,or � � - a ceitified copy thereof(Sec.3800.Lab.C.) , . ,.. .. . . .,.., - ' '� - ' �� � FpR APPLICANT TO FILL IN ,7pg >�6 lJ�i�-H x�.e�.a� � vA Policy No.� - �� Companv��� EACH NO. FEE ADDRE55 OX� G �❑ - � � � New Residentiai Bldgs.&Pools Certified copy is hereby furnished. 7&2-Family,Sq.Pt. 5 — � LOCALI7Y ��j� �N ,�� 'Q ' ' - ' - " -' " -- - Multi-family Sq.Ft. NEAREST Certified copy is filed with the county building inspection pp�� CROSS ST �,�e%}� •department. ResidentialSwimming�5 OWNEROR- /� �„ p�, FIRM NAME V�N � d�-y-A��S%^ Daft � Applicant Outlets:Rec.1 Ligh. Sw. � h MAIL ^� C., ,�- ' ' � ' First 20 � � ADDRESS `f?y .�'-i�Sl ��0� L✓ CERTCPTC.4TE'OF�EXE�iPTIONTkOMN'ORKE2S'� � TotalNo.� Additional -� �COA7PENSATiON INSL'RAi�CE " CITY /�.-fy'/���'/`,� Tel No. "'','�--7-�Z'7 �„ _ . �` � : - � P�AN CH�ECK � �- (This section need not be completed if the work involved � �APPUCANT O b - � Lighting Fixtures First 20 y the permit is for one hundred dol(azs (5100) or less.) j,,.r - aooRess � ' Total No. / Additional fr I certify thzE in 4he perfurmance�of[he�work fot�w�hich th�is CITY Tal No. ' � permit�is issued,I�shall not em lo-an� Fixed Appliances Not Over 1 HP I"' p y 5 person in any manner PERMIT � � so as to become subject[o the W'orkers'Compensation Laws. Range_Heater_4W._ APPLICANT ��4-Hdf�'^ v¢ l�L.-�I� .�,6,.'9� 'J�i Oven ,_Dryer_W.M._ ADDRESS qd� S.�['S; �p Z ... Da[e�j1��.Applican[���'�`" ��L�'��"�'�'"� YoP _FAU _W.N.,_ / Hood_Fan _Other_ CITv�'�_ F/� S����-�,el No.�'c��'�`7� N07ICE TO APPLiCANT:�'Tf, 'after makfng this Cerfificate of Disp. _Room Air Cond._ LICENSE OR �6��� '�Exemption, }�ou�should become subject to the lA`orkers' REG.NUM6ER �lass G�� Compensation provisions of the Labor Code,you must forth- power Apparatus&Large Appliances oISTRICT NO. PROCESSED Bv with comyly w•ith such provisions or this permit shal] be deemed revoked. Size&Type HP,KW,KVA,or KVAR - .. . � Up to 1 Incl. `� � Over 1 to 101nc1. FiNa� JJl - I.ICENSEUCOY7RACTORS'UECI'AR.dTION ' DATE vr ��.�p„.� VALIDATION . - Over.70 to 50 Incl. 6�'�1 FINAL [hereby affirm Ihat I am licensed under provisions of Chaptet Over 50 to 700 Inc. g�, J 9 (commencing with Section 7000)n}'Division 3'of the Rusi- Over 100 i"" ness and Professions Code,and my license is in full torce and r effect. Services I Lic�yense Numlier��°0�7� Lic Class � f� 0-200 Amp.Under 600 V , /.�'�rVyY� �yF.LT/�� c� n 201-1000 Amp.Under 600 V Contractor���.,Date J�ja"d � Over 7000 Amp.or Over 600 V HOME OR'NF.R-BURbER DGCLARA'IiON Temp.Power Pole&Appurtenances- , [ hereby affirm khat I am exemyt from the Contractor`s- Sign with One Branch Circuit License La�v for the folloiving reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): � _ � � � � Misc.Conduits&Conductors :, as o�mer of the proper[y�,will do the work and the pther ISee Complete Fee Schedule)— c 1, �Q,`y�}� structure is no: intended-or offered fqr sate (Section - 7044,Business�a0d Professibrts Code�.� t�,�'o n o e a'2 CONSTRUC7ION LENDING AGLNCY I hereby af£irm thxi there�is a coiistruction lending ugency � �T e G C,9 Q for the performance of the �eork fo� which [his permit is� pERMIT FEE (5ub-TOtal) issued(Sec:3097.Civ.C.). y��c r� � Lender's Name � _ PLAN CHECKING FEE (One-Foutth Permit Fee) u � Lender's:'�ddress . . PERMIT ISSUWG FEE C 3' � ��8` � I certify Ihat I have read this�application 5nd sfate that the� TOTAL FEE �'� � above information is correcL I agree to comply with atl�Coun[y . ordinances and State III115 regulnting Etectrical k�ring, and hereby:iuthorize representatices of this County to entzr upon - � the'S6ave-menrioned pr perty for inspection purposes. . ... ..:,.............t._..:.�.,....,.�...,-..._...............�.w...__... .... .___.._ . � SEE'REVERSE FOR EXPLANATORI'�liANGU"A�E.�� - �x��l�! J� ' Signature of Permittee ate , , (3"�VR�R-BUi1.3EIZ I)ECL�1R?�Ti�1V � �� �?hemby afiixm-ti�ei I•zr,i e:;empi trom ihe Car!racear's .. . .. .. . ... ... . � . . _ . � - .. . . APPFGUALS � DATE f.N.'>PE�;TOi3`t� . - ^;e :,v.: fc',:' ?i'-E` :ci_o�.+;i;ig Fea�ol:j3ec±rnii %035'.3. , .� . . ,�r ,. .�- . � -- - � ...-. .��sin�s:; �.nd Professior.s tiarleJ:-rin.Y cify oY cou�ty SICtiATURE 'I ...:. .. .__ ' ` _ . .. ' ' .. . . � ��� - TEMP."OWER POIE -- �� � i:'�YICN iC'QG'EPPS ff N*PP'r�flt i0 fGi:S:I'f:Ci� ale'er, improi•�, ..� . • . � .. . " . _. . . ... E ...... � .. . . rem .:,h, o-;en3ir an srru �;.Hrie ro its is ors r. .... . .. � ' " UYDERuLAB VJORK .. �"qu E i� GUpl CJ `fl"�SucP+ erm�P I 5lft (c ' '� __'__ � f�r.ro ,c Y e e v^ t1 II, .�p . c, !2 -..._ / ' � ROUGH CCNDUIT ��� � n .�g��P¢ 3t'rm2n t%qi`Yte f5 liCC'R5'E¢ /7UrSIlGPxi [O in2 .: "�. �. ��. '�.' �N RINC . � �� �� � � "��'N . . 6j'he CoNt;uCinT's LeceH.se Ctlw (ChaPter: ,�ra�Fsu�i�s , � _ � _ � � . '^_Ofn,1'�rn.t>l� W.r1T u¢ii7Ull %(%JOf Oj�17tY5IQR 1 L'f.thP � . . �IY.'.-U`lES ' ' ' . -. -�. �� _ . : .5tiS1RESS Qt)Q k"Of213<6::R (,fi�2f O� ihRd Idf id exEiiF�): � �.... . raerejrom ar�d the�5asi;iv�t�+e n7?ege�i ex�erEptior�..�iri;; . ' -. .. " . .. POVVERAUTHOR!Z'tD -�— I - vio(a?ionojSecfanlJ3l..ibyar.Y'app�ic�nr;oraPer;r.it �unu'rv ca.No7iFi'r�—��— � � � ;uhje��rs the ap,�?icc:t¢ro e ci�•rl per.p:ty qf not more tP�a� i . � ' - iit'�hunJred rfoilats;SSOOJ.: � � . . . FiNA� � �.'�..��lir�. �� . � : . . ... -^;,aa oaner oi ih2 proper`y wiif de�tfie�ivo:k.a��c . . � ;i;e s:xu;k:�r�i�7oE ir.;ended or e.feTed for sale. uores � , . ... . � JSec. 704v, nu;i�eeas and Professior<s C`ode: Tke Cnr- . . � . . rrac:rnrs Lir.esse Fax�.does nor_¢pplp �o am owrter o( ___ ____-__. ._._ , . _.— n„e�er;;wne i�vilda or:�3F�rrno2s t,9arror.,ar��,•'vrko rloee� - , . . . ' 'xuch x•Urk��hi,zu•etf prapitied th�: ��wc•h ?moroveneenta , � � � '— , - are-n.or i3�tended-or�oil��d}'or sa!e. 1p',�ho+,+ev�;. :ne , . � - . � � ' . ` -� .iuiiti:+;g nr i?a�uovement k soiG wittqir: oree y�ear pf --------------- � ,•omrletior., �i¢e ownrr-i�uitder wit? have zhe burden . . '. . . . .. ... � , o,*grei'ir.g_tlra: he did :iw 3uifd er irrpJv=ve Jcr rne ----------------- . . - p:rrpo.ceofsale.) � . . . � -. . . � --- ' ---'-.��_...__..�._._.-._.._.�_____._m...._._..__.-_----------- " _. _....:e�:ei���i tu:�er 3�c. , -- — — ---. ---- — �S c�r P.C.for t3.is.eason .._ �v���r..� ; :' ; .