HomeMy WebLinkAbout1594A (17) WORKERS'COMPENSATION DECLARATION 75A6W 10/BI �OC�� '
I hereby affirm thot I have a tertiiicate of�o�,e���o=e�f �E.� . APPLICATION FOR ELECTRICAL PERMIT � ��.,�
ins�re,o�a cer�ificate of Workers'Compensotion Insurance, , �OUNTY Of LOS ANGELES BUILDING AND SAFETY��
or a certified copy thereof(Sec.3800,Lob:C.) -
P�ol7cy No. Company � � FOM AVPLKANT i0 flll IN . JOB
Certified copy is hereby furnished. New Residantiol Bldgs.&PoolS EACH NO. FEE AD�RE55� � ilJ A �Y�.
� 1 8 2-Fomil LOCAIIN
Cerlified copy is filed wilh Ihe co�nry b�ilding inspec- y,Sq,FI. f — f � Q
lion depOr�meM. ' MU�ti-fOml�y$q.FI. — NEAREST ,,
�RouST. �v ve,vue
Dote ApplimN Residenlial Swimming Pools OWNER OR. /�
FIRMNAME ,(J LO EIVI
CERT�FICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.�Light�5w._ - � �'�� �
COM�ENSATION INSURANCE A��u ' L N1 IG L VD.
This�Mion nwd not bs com lefad li fha work tnvolrsd b First 20
� P Y To�al No.� Addifional � -GTY �Nr� �-Tel.No.
fha permit ti for one h�ndred dollan(SI00)or lass.) � p�AN CNECK �
I certify thar in the performance of the work for which this � "-� APPLICANT "
permif is iss�ed,I shall not emptoy any person in ony manner
so as to become subject�o the Workeri Compensaiion Laws. ��ghting Fix�u�es First 20 � _ ADDRESS
To�al No._�,� Additionol
pa„�'l7'kY ApPlicanf�aFELeeT.P/G CI7Y Tel.No.
NOTICE TO APPLICANT: If, ofter moking this Certificate of Fixed Applionces Not Over 1 HP PERMIT
Exemplio�, you shouid become Subjecf to the Workers' Ronge_Healer_D.W._ APPLIfAM .� E ec
Compensofion provisions of Ihe lobor Code,you must forlh- Oven _Dryer _W.M._ ADDRES$ p �A Q � ��
wi�h compty with such prorisions or this permit shall be Top _FAU —W.H.—._ ��Ty N.r Tel.No. �p
deemed revoked. � ' - Hood _Fon _Oiher_ •
LICENSED CONTRACTORS DECLARATION � � � IiCEHSE OR .
I hereby affirm fhot I om licensed under provisions of Chopter 9 Disp. _Room Air Cond. _ REG.NUMBER _ .� � Closa.C � �
(commencing wilh Secfion 700D)of Division 3 of the Business DISTRICT NO. PROCE$$EO BY
ond Crofessions Code,ond my license is in full force and eifecL _ Power Apparatus 8 Large Appliances _ _. . a
p Size 8 Type HP,KW,KVA,or KVAR� l� ��i Q
lf[ense Number���3�/� Lic.Class L�� Up l0 1 Ind. FINAL .� I/ � .. .- . V
CoMracto�.`��ELC-'G��/G Dme a��7'�� Over 1 lo IOlnd.. DATE cC al p'( VALIDATION ... O
9
❑ Over 10 fo 50 Incl. FINAL ~
I vm ecempt under Sec.� Over 50 to 1001no BY w
8.8P.C.for this reason OVef�� ����'� y
. � . . Servicea CC 8 Ponelboords � - �Z
DO}e' 0-2bD Am . nder 600 V
$ignolure 2b1- mp.Under 600 V � � -
❑ Over 1000 Amp.or Over 600 V . �
Exemplion(or Reg.Moint.Elect. - �
SINGLE FAMILY Temp.-Powar Pole&Appur�enances $1 5 9 4 A
HOME OWNER-BUILDER DECLARATION. Sign wilh One 8�anch Circvif ${,� � � � �.L
I hereby offirm thot I am exempl from the Conlrotlor's Litense q�itional Si n Branch Circuils
Low for the followinq rrnson(Se��ion 7031.5,B��:ir.e:s end 9 � • •b��5�
Professions Code):
❑ I,as owner of the property,will do rhe work and rhe Misa Conduirs 8 Conductors ' • • .6 1.�5 p c=�.
slrutlure is not inlended or offered for sale(Settion O1her�See Complete Fee Schedule)_ , s�
7044,Business and Professions Code). � ��,��]—8[j
CONSTRUCTION LENDING AGENCY . �-� . .
I hereby affirm that Ihere is a consfruttion lending agenty for
the perfo�mance of the wo�k for which this permit is issued PERMIT FEE � �� � (Sub•iotol) �� �d � - .
(Sec.3097,C�v.C.�. � - � .
' PLAN CHECKING FEE - �
lender'e Nome uh T� � N - . . �
.S� 71 R N/p�/ O �e, pERMIT ISSUING FEE . � �O , �
Lender's Address L• L �
I certify thm I have read this applicatian and state that the TO7AL FEE. G�• S - - ..
obove�niormotion is mrrect.I ogree�o comply with all Counry , , .
ordinances and S�ate laws regularing Eledrical wiring,and . _ •
hereby a��horize rep� sentotives of Ihis County to enter�pon . � '
rh obove•men' rope�iy for i ecrion purposes. SEE REVERSE FOR EXPIANAYORV LANGUAGE
a—��—s�v .
igno re f Per inee Dole � ' - .
� . -
. ._ _ _, „ :. . .
O Z � � TX � O Z ^'
. :.m D � -1 � C p � . .
. � r -/ C Z � m � -
� n D � Gl = An �v
- O C n � � �
. � O �o � x,
Z p p � A �
' .- 0 m � � O N .
• m p
O • •
�
'..
�
, � ,
O
� ,
� � D ,
1
n.
i
i '
�
�
Z
, D
�
C
A
m
' . _ . , _ t I.- . � .. .:
J •
, ' '' f�� � , �
� . r . , `/,_ f
� . ' � _ . . ' ' . . . '
. " . O o � o + f 3 ' o �-o v�- o$ oo'" �0 3� o � m�_
� m a' 3 d.�� � i�„o •','� �°, q� �' H -�- ' �wm��� m
' � � n . �X ' �' o-� o�-�no� ❑Ho �mo� � �-�oNNm �
- o °-c � °-3-•� ac' .'^a'� o °-"�°o' ao5�
� � . . p � 3 � i �4 1 `N Q m m � N�1 O �O N-S q C'D � � T .
, . v �i o �.� �c .�g`��o:�r-�.a� t� �- - �� .
1 C
� ' S .C � N aj� � O M N F . �O N � O n�"�T 3 �O 3 C
. . . � . ' M . ) � F N 1 p F N 0 7 •.�� C`S'••O �'� �O . Z
n. � —o ° < 3a -� ° �be�.= buo �c Nso A
�: . 'a � o '"aaiaa ° " � o . o :, k �-� m � ^ o'
� O C O � � N 3 fD � � C N n m O G n �� � �
- . � l� CNJ l � F N �0 , 2� S � �� N O � CL N Q 7 N O p C .
u ' Q A ._ p, '
, . .. : , i . � . 7 �fl �.m aS j�� j-O O O_'D O O % W�L� �� C O`2 fp v
� � . � � � c 7 �� �ti M �-e o O ? 3 � Q c b �.'�' a� x � -
. . . - C � m w 'O w O m �'fJ m � .
� a m �.�.o'� �,m �m �' �-b � � p �� � m
, . ' v �u.� 0 3 � o D Cl
. o � m ° � o � m'� 0 3�cT� -, o : °� °o -«
� �o <� ; jn�� 04�'� �.u�,o „�= oo �
' � °.� O.� oao °cti-•,— Sc ° �"�c _M3 ' 3 D
» � � ' o F m $ o• � o:°� � �v o c�°o i� _�
� .°� 3omo� �oT ..'�° ao " 3 < N � ° � � o Z
�-`°bs3a°.o° �' o` ; oa> > "�@ ? c° oo
'� � '" °vn o �-S',�a._� opo� � 3
' • o" a� N o' o ;r c �0 �n� ��0 4 w 3 `� �o
�? � � N� > > o � c-o °'^ ooE $n
�° � cw ' o. av -. o f $ ��'_o
. arv o o S,� n a ab� N � =;�?o m rs�„ N.' -