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HomeMy WebLinkAbout1293A I ��WOpKERS'COM17PENSATIONDECLARATION 76A663 �o,e, qppUCATION FOR ELECTRICAL PERMIT ���� � I hereby aflirm ihat I have a certificate of consent t�sel(insure, c68osG � or a certit�cate di workers'Compensatan Insurence,or a eertitied COUNTY OF LOS ANGELES BUILDING AND SAFETY cq�y thr,reof/Sec.3800.1ab.C.) ' f PoliCy No.��CAmpany FOR APPLICAN7 TO FlLL IN . . .. �1'` /'1� � n f0 � EACH. NO. FEE- DOReSSI�lJv 'S IfJM^'�0�� 7�� Cerlifietl copy is htreby.tumished. New Residential Bldgs.&Pools e� - � 6 ❑ 162•Famil � S — 5 - LOCALITY� �a./lp.� . CeNllietl copy is filed�with the cWnty building inspection Y•��F�� _ Mulli-tamily Sq.Ft. NEnnEST. • � departmenL . . ' � � � � ' CROSS ST. �i le��Applicanl a �a rr�z Residential Swimming Pools � � - ��� wemEa oH .+►�� - /'y¢��.// . FlRM NAME aJ�- f � L /, CEFffIFICATE OF EXEMPTION FROM WORKERS' p���g;Rec�L'ght�!SW.� ' � -� MAI� � e -COMPENSATION INSURANCE � �� -�S •`-� AD�RESS a (This sectton need not be completed if the work Invdvod by the � Frst 20� 21�t�. .y�� permit Is tor one hundred dofiars(S1001 or less.). . Total No. Addiibnal qTY . Tet.Na ,W �v �I Certify�hat in the peiformanCe oF the work�or which this permit PL.SN CHECK ��.—. �1 AI'PIJCANT is issued,I sha9 rwt empioy arry person in arry manner so as to / ADDRESS --�� become sublec[to the Workers'Compensation Lavrs. �ghtirg Fixture9 Flrst 20 �� � � . . . . . Total No.�_ A�iibnal . CITY ��-- � Tel.No. --� Date � Applicant � Fxed Apptiances Not Over 1 HP PERMAT NOTICE TO�APPLICAIJT: If, atter-making this Certificate of nPRiCaNT- Ezemption,you shouM becomo subiect to the VJorkers CompensaYan Rango_Heater_�W. ` . provisions ot the LAbor Cade,y�u must fortirwith ecanp".y with such OvEn_Oryer_W M._ � ADDRESS a x �1 ,provisions or this permit shail be deemed revoked. . _ Top _FAU. W.H._ � CITY" �- � Tel.NoZ�3 276 6q I�CENSEO CONTRACTORS 0£CIARATION Hood_Fan � Other_ ucENse on I hereby aftirm 1�3t I zm Iicense0 unCer provisions ol Ghapter 9 . Disp. — Room Air Cond.-� � •� REG.NUMBER C�ass. (commenciog with Section 7000)of Drvision 3 of the Business aM Professions Code,and my license is in full force and effxt. p�r Apparatus S Large Appliances ' D�STpi�T NO. PROCESSED ev _ . . ._ .... .. ._ /d o. rrr...AAA A O Size 8 7ype HP,KW,KVA,or KVAR U �y�'�/rn FlNAL Lbense Number�Lic.Class Up to 1 Incl.� �- - ��� � My Over 1 to 101nC1. �ATE ,��.�j YAUDAl10N . 0 Contrattor/ '�f , � Date�_./� . .. Ovcr 10 to SO lnd. FlNA � C~.� ❑ ��m exempt under Sec. . Over 50 to 100 Inc. BY -� - -� � � a .C.1of Ihis reasan Ovcr 700 y Services,Swbd.,MCC&Panelboards � ' �" �- -" � � �-�� ' � ��- ' Z . 'Oa!e: 0-2�0 Amp.Undfr 600 V:✓ Si{ ature 201-1000 Amp.Under 600 V �� � �� � - -�� ���� � � - � ❑ � -� � � ��� O�er 1000 Amp.a Over 600 V ��. Ex�mption for Reg.Maint.Elec[. I �� ' � � S!NGLE FAA",ILY �-� � �� 7emp.Pov+er Pote d Appurtenances . ._. ... . . . . .q� A 29.3 r NOME OIVNER-BUILDER DECLARATION Sgn with One Branch Circuit L �� I I here4y aflirm ihat I am exr.mpt trom the Cootiador's License Law for thn followirx�rPacnn(Sr+rr�np 7031 F,Bu�E^=«2.^.'!?f=�ossio•^•7 Additional Sion Rranch Cirdiit5 - . . . ... . _. .. .. H• • • • •[ Code): Mfsc.Conduits&�Conductors " �� ' � � - � � ��2 2 5 . ❑ I.2s owner ol thr.property,wiil do the work and the structure • s •rj 2,2,rj�� is not intended or olteied for saie(Section 7044,Business _. a�r ISee C.ompleto Fee Schedutel_ , _ and Professions Code). O�.O 2�8 7 CONSTRl1CTION LENDWG AGENCY � -�� - � - � - � � I F�emby aftirm that thae is a conslnxtion IeMing a9ency for the pe�formanc�of the work for which this permit is issued ISec.3097. pERMR FEE' � ��- � � -� ' ' (Sub-Total) � - -�- � � ' � � � - Civ.C.1. � . PLAN CHECKING FEE � � � �� �� � - �- - � �- - � � - � � Lender's Name . PERMR ISSUING FEE. . . . . JD O --._ . . . . .. .. .. Lender's Address • � L� q 1' � I certi(y tbat 1 have re2tl this appt'�cation ard state that the obove �TA�FEE V��v4,� _ ..- ._ . - ., . informatbn is correct.I a9ree to Comply witb all CwMy ordinances and Sta�e fatvs regulating EI ri�al wirirg,a here6y auttqri:e .,, . . _ .. . . _ . . . ..... . - representati s of this Counry en[er upon he above•menti0ned property f r ii�pection Wrpos �. ._ SEE REVERSE FOR EXPLANATORY LANGUAGE-�� � . � - � 'ignaWre f ermNee Date � E'� . _.,..°:.,.: �. .. . . i --� � -- ; -�. - i�. ._�_ _ .��_;;_..i_._.; _�._.. - ' Ii �,�y ' � � ; � � V,�i:� � i I ,"1 C%r . i ` I .. � { ! ;�,� - '^ _ f .�• ; 'r ,_ a . 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