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HomeMy WebLinkAbout1634A (17) � _ r . -�WORKERS'COMPENSA'IIONUF'CLARATION �*� 76A663 �. ��p.p��CAT��ION �FOR'�ELECTRICA,L��PE�R�MIT� {��..� � �:� CE�806G(2 SO) � r hereny a£firm that [ f�a�e a cert�ricate of consent to se�f,j COUNTY OF LOS ANGELES c,; BUILDWG AND SAFETY �I insure,or a certificnte of Workers'Compensntion Insurance,or.�.', � . . �-:-a certified copY thereof(Sec.3800,Lab.C.) � � ��,,��r� �p(`y{.,�.. 1/j FOR APPLICANT TO FIL�IN JOB n � .�ynlicy�eis�-�1JL-Y�7J�mpanY�a'JJL4�`�+.�t�1%� EACH NO. FEE ADORESS (� �,�( � [JY �� � O � New Residential 61dgs.&Pools ` � Certified copy is hereby furnished. 1&2-Family,Sy.Ft. $ -' $ LOCALITY i � �, � � � 'Multi-family Sq.Ft. — NEAREST y} � -� Certiticd copy is fited with the coimty building inspection ��� CROSS ST �3y� __/`.-e �� depnrtment. :. Residential Swimming Pools OWNER O �y �+�, /� rp 1 +1 _�$ � FIfiM NAME C.�+4'FCU�� � `Duta���APPlicant+^{��'7'�di{ ���a�����.. Outlets:Rec.�Li9h1_Sw._ � MAIL . First 20 ' P.DDRESS_ _ _— . CERTll�ICATId�OF L:XEMPTION FROM WORKi:RS' - Tota�No.� Additional �- _ � aTY , -� Tel No. '. �� . .COMPENSATION INSUAANCIs �PLAN CHECK n' . � � APPL�CANY ..�� . (This section need not be complcted if the work involved .� - �� � � �by Uie permit is for onc hundred dollars (5100)or IessJ �'• Lighting Fixtur(e's � First 2D �� . ADDRE55 a . � � Total No.� Additioqal ` p� � i cer[ify that in the erformai�ce of the work for wtiich this ' � � CITY ____Tel No. (-� . h � Fixed Appliances Not Over 7 HP i tJ�� permit is issued,T shall not employ uny person in any manner � � � PERMIT � � �•� ip �� ��so as to become subject to the Workers'C�impensat�on Laws. Range._Heater_D.W. � APPUCANT � � ..�Y7£�•s s.�.� Oven _Dryer_W.M._ j AODRESS �.�. � � , ��1��3 fl.� tt 1` Ilnte Applicant �,� 7op _FAU —W.H._ CITY-'� Tel No. . - : Hood—Fan —Other_, q . . �� '' �� �.N01'ICE TO APYLICANT:lf,af[e�making this Certificatc ot � Disp. _Room Air Cond,_ ' LICEN E CR � � �.� -. Exemptiun, you should Gea�me suA�ect to the Workers' � . .� REG.NUMBER ca�.+-'3� ' Class ��.��Compensatinn provisiuns oF the Labor Code,you must farth- �� Power Apparatus&Lar9c APPliances L �ISTRIC7 NO. PROC�ED eV ��! �vith comply with such ptovisions or this permit Shatl be � gj�e&.Type HP,KW,KVA,or KVAR � r ��� ����deemed revoked. � .� �� �~' ���'~��.� � ; ��� 4', Up to 1�nCl. _ � $ . FINAL � . . - :� Over 1 to 70 Incl. OATE - � � O� �. � LICENSEll CON'fItACTORS DECLARATION �VALIDATION T Q Over 10 to 50 Ihcl. ` � . � PINAL !' . ..� � I hereby affirm that I am licensed under provisiuns of Chnpter � Over 50 to 700 Ina �,. � i �,�.9 (commencing with Section 7000)of D vi ion&nf the Rusi- Over 100 ya��j � .�ness und Nrofessions Code,and my licen e is in fu1L force and � � � � eefect. � Services C ��� � 0-200 Amp::Under 600 V ,t� +� License NumNer Lia Cinsv_ ZO7-7000 Amp.Under 600 V � � �'�l . I ! -��/ . ` {�� Cont �y�0 �. Over 1000 Amp.or Over 600 V . . �--Lf'-sZ-�-- �t , ; �' HOMI?OWNER-BUILDER DI?CLARATION �)Temp Power Pole&Appurtenances 3 � � z I U J,4!+. � �� Siqn with One Branch Cvcurt r � ` t� I 7 herebv affirm that I am exempt from the Contrector'S p ;,,,,,,i c.�..g.� r..C.�yrg ___ ; #�a m.e o�L'� �. � �I.icense Law for[he Following reusun (Section 7031.5, 13usi- � """" � � `.; ness and Pmfesaions Code): � j � � a e � �,9� '- �� ���: Misc Condwts&Cnnductars ; �� .��� � � I, as owner uf.the property,will Ao the�vork and tlie `�,�pther(5ee Complete Fee Schedulel--�. , n �:� '� O,��,{j�, � structure is not intendeJ or offered for snle (Sectiun � � "� 7044,Business nnd Yrofessions Code). � � �e, . �l.r�.�'�'y l � CON51'KUCI'ION LENDING AGF.NCY � � - - ��., f hereby aFfirm that there is u constructiun lending agenc.y . �- ' fo[ the performanee of the-wock for which this yermit is 'g� pERMIT PEE (Sub-Tota�) �'�` issued(Sec.3097,Civ.C.). � �. � � �� � i,endcr's teame -- ::; PLAN CHECKING FEE (One-Fourth Permit Fee) � � � ����+ . , � . . . . ��i Lender's Address - �, pERMiT ISSUING FEE � 1� - .c:, � . �i Ti -]�certify thnt I have read thia flpplication and state thut the �,`� TOTAL FEE � �. ��� �abuve information is eqrrect.I agree to cnmply w�th all C�n�nty ; �, Iordinances and State �a�vs regWtiting Electricul wiring, and �Q.r:.� �S�j��9���� � ;�, }., . hereby authorize representatives nf tttis Cuunty[o enter upon � � the above-menti ed property for inspection purposcs. 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