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HomeMy WebLinkAbout1702A (19) •WORKERS'COMPENSATIONDECLARATION 76A663 �0�8� qppLICATI�N FOR ELECTRICAL PERMIT � Lherehy affirm ihat I haqa a tertificate of consent to self insure, CE-Bo6G or a certiticate of Workers Comcensation Insurance,or a ceni(ied COUNTY OF LOS ANGELES BUIIDING AND SAFETY � � �� copy ihereof(Se 3800.Lab.C.) • Policy No.���JOZ4GOmpany FOR APPLICANT TO FlLL IN - �B �y_-_�,,�l � - EACH N0. . FEE ADORE55 ! �W'►U+� .,Certitied topy is hereby fumishetl. New Residential Bldgs.8 Pools LOCALITY '� . Ceriified�COpy iS filCd with�fhe Coun�y building in5pettion 1 8 2'Fdmily,Sq.FL S — � NEAREST . / �dePart nt. .. ... , .. .. ._ . Multi-Family Sq.Ft. CROSS Si. ' t'r'Oate Appiicant � Residential Swimmirg Pools � -- � OwraER OR , \ �//�/ FIRM NAME - ��C RTIFICATE OF EXEMPTION FROM WORKERS'- � p�tlets:ReC�LSht'_LG SW.� . � MAIL �� �COMPENSATION INSURANGE� , -� . s� �/r}�ADoaESS (Th{s aectbn need not be completed if Ihe xrork Involved by the +� '7 Frst 2D CITY.. _ ' Tel.Nod�.�'� permit is tor one hundred dollara($100)or less.), . � Total No.�L. Additional �� � , PLAN CHECK I CCftily�hat in the peff0�rtf3nC0 ol,the vrork f0!whiCh thi5 pemlit ' "' APPLJCRNT ' ' ,is issued,I shall not employ arry person in arry manner so as to � become subject to ihe Workers'.Compeneation Laws. ,, L'ghting Fixtures First 20 � � ��� � �ADDRESS - � ��������-- � - �. � � .. . Tofal No.'1� Additionai � ��TY . _ Tel.No. Date AOP�icant Flxed Appliances Not Over 1 HP • �NOTICE .TO APPLICANT: If, after�makirg. lhis�Certificate of pEa�tii Range_Heater_DW. _ a�'�cAM � Ezemption,you should become su�ject to the Workers'Compensa['ron _ _ . - �-� provisions�cf the Labcr CoCe,you must forihwith cemply wi!h such Oven_DrYer— W.M.— ADDRESS � ` pmvisions or this pertnit shall be deemed revoked., ,..Top —PAU._.W.H.._ . _ ' � - - -�- -� CITY � '� " ���Tel.No: �,,LICENSED CONTR4CTORS DECLARATION .� Hood— Fan _ Other_ . .;.. L�CENSE OR .I hereby�aflirm that I am licensed under provisions�01 Chapter 9 _ pis — Room Air Corb. _ -���� � � - ��azs� � � P� REG.NUMBER (Commencing with SeMion 7000)of Division 3 01 the Business and P(OfZ55i0�5 COtlB,ZOd Rry IICB052 IS Ifl�llll(OfCB d�d Bf�2CL' PpqR;f App3182U9 8 LBfJE Appfl�nC25 �ISTRICT NO. � PaOCESSE�BY _ /� /� .. � G V✓ /D (c� Size�Type HP,KW.KVA,or KVAR � � License Numb Lic.Ciass �""'� Up to�1 Incl.� FlNAL Over i to 10 Incl. DATE , _.�./.� VALIOATION �� . �, / � Contraeta �'Date . . . .pvert0�to501ne1. FI L ` .. -� U ❑ I am e.empt under Sec.� � ___ Over 50 ta 1001nc. BY . .-- -�� --- - . _ . . . . _... .. . .. _ .. 6.8�.C.�or this reason Over 100 . �'.._ _.... z - Services�gy�-�.'.IC�.B�boa_�ds � - , - .. . . . ,,,,, ....._._ .. . � Datei._. ___._. o_C"�onn m,;ii,w�.ann� - / � / �► ' Signature - �201-1000 Amp.Under 600 V���� -— � �` � � - - - � � -� �-� � � -� � -�---�-- � � � O�er 1000 Amp.or Over 600 V � Ezemption tor Reg.Maint.Elect. � --� � � �- - � � --- --� � � � - - �� - � - - �. -� - � - �� �-� ��� � � �SINGLE FAMILY �--� - � � Temp.Power Pole 8 Appurtenances � � HDME OVYNER-BUILDER DECLARATION Sigri with One Brench Circuit I hereby affirm ihat 1 am ezempt trom the Contrador's License Law for the followirg reason(Section 7031 a,6usiness anJ rmtess�ons A�ditinnal S�gn BrenCh Circvits___ . . .. ..�7. (1`�A Code1: ❑ Misc.Conduits d Corductvrs...._.. . - . . .. . . . .r�• • • • •2. I,as owner of the properiy,will do the vrork and lhe structure is not intended or olfered For sale(Section 7044,Business 01her(See Complete Fee Schedule)_ � _ � S •4 9.5 0 _ and Professions Codel. .... . . . ... �... ... . . �- � - ... . ._.... . . . • � •49.50� CONSTRUCTIONLENDINGAGENCY � - � " �� �- "- --- " I hereby alfirm thzt there is a construc[ion lendirg agerxy tor the 0 9,1 6-8 7 ' performanCe of the work for which this permit is issued(Sec.3097,._.. .pERMfT FEE -�- �--- --��� I�b-Tota�)� � (.� �� � �-� ����� � -- - ��-� - � Civ.C.l. I � . PLAN CHECKING FEE.-- - -_...... ...-".-- � __- -� -.._ _._ . ..- ' -..... . .. ... . . ._ _ ' Lenders Name � PERMRISSUINGFEE_ _____. .. ., ,.._ I(� .., . .. ._. ..... . _ .. Lenders Address � I certily that I have read this apPlication and state that the above TOTAL FEE _ ��•,� , ' ' . _ . .. ..... _. ._.. .. ._, . .. . . . .. . ... . ..... . infamation is correct.I agree to comply wi[h ali County ordinances , aM State laws re9ulaiing Electrical wiring,and hereby authorize , . � representatives of this C nty to enter upon the bove-me ioned - �� � � � � ����� - �- � � p � for inspection poses. � 4 _y �` . _ SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ _ _ r� J �_ Sig re of Permit Dat . � . � . . � .. , / . i �� ._�t!~I. 1��... . ,� �-��1 I . i _ __"�.. ��. �.� ;�.-��..-.1_ _ ' :li ~. .I� �"I�..��� '4..���� ' . ' � � . I � � i ; ,i�`'� !I <<..i � '� ;�-^ : • _ , �j ' `�, � � ' j���' ' � I !"� ( _y, . � 'i i . '-_ , i , , -- � �I ; �='� -,•- ;_, , � i ,, , � i '� ; ; ; � I j � ��:� �-� ! '- '-_ : � � `. . 1 I I, i-. .y� i,-�j = -- — : i i '� i T I I j (. I I I � i �`.` �r,,, 'ti T C � '�1� '�`� �C -1 � L '�� . � " : ( , � / D D C � -1 �' C O �. _ . 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