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HomeMy WebLinkAbout0850A � i�� ,PENSATIONDECLARATION ' 76A663 APPUCATION FOR ELECTRICAL PERMIT � . . � f CE-9D6G(2�80) Jy��1`s' c I have a certiHcate o�consent �o seI[ : COUNTY OF LOS ANGELES BUILOING AND SAFETY . ete o(Workers'Compensation Insurence,or � . �� � ereof(Sec.3800,Lab.C.) � � � -� � �� � �l935oS/oc��t�c-r-������� FORAPPLICANTTOFILLIN JOB f� (� _Company � EACH NO. FEE Ap�RESS \1 l �u ,�6� '�j �\ � � New Residential 81dgs.&Pools J copy is here6y furnished. 1&2•Family,Sq.Ft. $ — $ LOCALITY �y � Multi-fam(ly Sq.Ft. — NEARE T ❑ Certilied copy is filed with the county building inspection � � CROSS ST Residential Swimming Pools Jepartment. � . , . .. ,_ OWNER OR / /. ! ' � � ��e :' ' • .'� - FIRM NAME C/d !� L«T �f'Q' Date�� APPlicant`��k!-•' �`T�'pe Outiets:Rec`j�{.ight�Sw.� � MAIL � � FirSt 2D �� Q �� ADDRESS CERTfiICATE OF EXEMF'TiON FROM WORKLRS' t � Total No. AdditiDnal �0 CITY Tei No. COMPINSATION INSURANCE ' PLAN CHECK } . . � APPLICANT 0 (This section need not be compieted if[he work involved � Li9hting Fixtures First 20 aoor+e55 V by the permit is for one hundred dotlus (5100)or less.) Additional Total No.� . � � I certity that In the perfnrmance of the work for which this � Fixed Appliances Not Over 7 HP C�TY� Tel No. O permit is issued,1 shall not employ any persnn in any manner PERMIT !�/ �� V so as to become subject to the Workers'Compensation Laavs. Range_Heater D,W._ qpPLICANT � /dwK I.iH� =�r� �C. W Oven _Dryer_W.M._ � ADDRFSS i —r �^ Date - � ApPlicant - . . . Top e FAU _W.H.._ � 7/`Z ��� � �V� Z � Hood.cr Fan _Other_ CITY ��a Tel No. �f��Z NOTICF.TO APPLICANT:If,afhr making this Certificate of Disp. .(._Room Air Cond._ � LICENSE OR r � Exemption, ynu shnuld become subject to the Wnrkers' . HEG.NVMBER .JCless Compensation provisions of the Labof Code,you must forth• � power Apparatus&Large Applianees DISTRIGT NO. PROCESSED 9V , with.comply with such provislnns or this permit shall be Size&Typ2 HP.KW,KVA,O�KVAR ��Q deemed revoked. ���p. - Upt01 InCI. ' FINAL ' Over 1 to101nt1. DATE ��,3 �a VALIDATION LICENSL•'D CONTRACTORS DECLARATION • Over 70 to 50 Incl. � . � I hereby affirm that 1 am licensed under prnvislons of Chapter Over 50 to.100 Inc. FINAL . 9(commencing with Section 7000)of Division 3 of the Busl- Over 100 ' � BY �ness and Profeesiom Code,and my licenze is in full force and � effect. � / Services � . License Numbe �� Lic.Cless ��b 0-200 Amp.Under 600 V , � r�/����/� � b 207-7000 Amp.Under fi00.V Contractnr�if�.4�✓�C�•-�!- Dete a� Over 1000 Amp.or Over 600 V � . , , HOb1E OWNGR•BUILDER DECLARAT[ON Temp.Power Pote&APpurtenances - - � i hereby afRrm thaL I am exempt from the Contractur's Sign with One Branch Circuit License Law for the following reason (Section 7031.5,Rusi• Additional Sign 9ranch Circuits . . ness and FMofessions Code): � � � Misc.Conduits&Cnnduetore . � � 1, as owner nf the property,wili do the e�ork and the Other(See Complete Fee Schedule)— ' ' structure is not intended or o(fered�for sale (Section � - 7044,Business and Pmhsslons Code)n ' . � - CONSTRUC710N LENI]ING AVENCY 1 hereby affirm tha[ �here is a construction lending agency � for lde performance of the work far which this permit is -�Q�rj Q A issued(Sec.3097,Civ.C.). � PERMIT FEE ISub-Total) LendePs�Name � PLAN CHECKING FEE (One•Fourth Permit Fee) � � . �• ' • ' •� LenJer's Address � . pERMIT ISSUING FEE i} (�` �.� 'S Q 7 Q T certity that 1 have read this application and state that the� �� TOTAL FEE s� Q •t• •$Q!�c=a ebove information is correct.[agrce to comply with all County ordinances and State la�vs reguiating Electrical tviring, and � � I �,�J O—8�� hereby authnrize representatives oP this County to enter upon . , � . the ov•mentip �pro rty for inspection purpo es. 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