HomeMy WebLinkAbout1586A (15) i .
WORKERS'COMPENSATION DECLARATION �76A663 toiei APPLICATION FOR ELECTRICAL PERMIT - �
I hereby ofiirm�hat I have a certifica�e of consenl to self �E-B06C .
msu�e,o�a ce�tifimte of Wo�kers'Compensaron Insvrance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cerlified copy�hereoF(Sec 3800,Lob.C.) � - �
aCy Na. Compony . FOR APPLICANT TO Flll IN DDRE55 ��S� f�����'t'/ "✓�2—
Certified copy is hereby furnished.� New Residenlial Bldgs.8 Poois EACH NO. FEE
� Certified copy is filed with Ihe counly boilding inspec- 1 8 2-Fomily,Sq.Ft. s — Z � LOCALITY Q' rypn,p �J�jL 7 �(//=
tion depa�lmen�. Multi-fomily Sq.Ff. — �A�ST � �N/1
� � - Residemial Swimming Pools � OwNER OR /
Dote Applicont � �
FIRMNAME VA�ti ��/��R���'�
CERTIFICATE OF EXEMPTION FROM WORKERS � Oollats:Rec�`�'LigM_Sw.� ���
COMPENSATION INSURANCE � � AODae55
7hh��Nton n��d nol ba com IH�d if fb�werk involved b First ZO
( P y Total No.� Additionol CITY � _ Tel.No.
�hs p�rmit I�for on�hundr�d dollar�(SI00)or bss.)
I certif thot in the rformance of Ihe work for whith this . - PtAN GHECK
permit�s issued,I shall no1 employ any parson in ony monner - AFPLICANi
so as to become su6ject to the Worker'Com en otio �ow� �Ighling Fi.tures First 40 AD�RESS
Totol No. Additional
Dare���'"yy e lic " -2 CITY Tel.No. �
PP Fized Appliontes Nat Over 1 HP PERMIT �1
NOTICE TO APPLICANT: if, affer moking this Cerfifico�e of - APPLICANT ��'J S /_��(%r/�
E.emption, you should become subject to Ihe Workers Ronge_Heater_D.W.�
Compensouon provisions of�he Lobor Code�,you must forth- Oven _,Dryer _W.M._ � ADDRESS ��i��/ � /f� �,�T�
wiih tomply with such�provisions or Ihis permit shall be Top ,FAU W.H.—
deemed revoked. Hood _Fan � CITY Go�a,�,� �i¢!,�/' Tel.No.9 /•y4Ss/
� LICENSED CONTRACTORS DFCIARATiON � , �O�her_ ,
��Disp. _Room Air Cond. — liCCNSE OR r . . �lass,�� ,
I hereby oHirm thal I am licensed under provisions of Chapter 9 REG.NUMBER 3?�VS/,�� �
(commencing wifh Section 7000j o(Division 3 of the Business DISTRICT NO. PROCE L�SSE B�Y
Power Apporafus 8 Lorge Applionces Y
and Professions Code,and my license is in full force and affed.� � - �/ y -
. . . . � , Size 8 Type HP,KW,KVA,or KVAR' � �0 nj it� Q
License Number Lia Class � � -Up�0 1 Incl. � � " FINAL - - V �
Over 1 to 10 Incl. DATE 3 ,��, � d' ,
CoNractor pote . VALIDATION Q
Over 10 to 50 Incl. F�NAL /l ~
❑ I am esempt under Sec. Over 50 fo 100 Inc BY +' . _ ., � ,
B.EP.C.for ihis reason Over 100 u���`f 2
� Dole: - Services,Swbd.,MCC 8 Paneiboards � � � � � � �
� 0=200 Amp,Undar 600 V. � �
Signalure � � 401-1000 Amp.Under 600 V � �- -� � �� �
O � � Over 1000 Amp.or Over 600 V .
f�emplion ior Reg.Maint.Elect.
. SINGLE FAMILY � - Temp.Power Pole 8 Appurtenonces
HOME OWNER-BUILDER DECLARATION Sign with One Branth Circuil � �
�ha...hy�i(f.m thnf I am n.ampt fmm the Conlroc�or'S License q�itionoi Sign Bronch Ciauits �
law for the following raoson(Seclion 7031.5,Business and
Professionz Code): - �
❑ I,as ownerpf the property,will do the work and ihe Misc.co�d�n5 a ea�d��ro�: �- .�� �1 5 fl 6 A •
. structure is not in�ended or oftered for sole(Section Other(See Complete Fae Schedule)_ ► � �� � • � ��2�
7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY - � � � - - � I •��4 2 5 0 �
I here6y affirm thar ihere is a mnstruttion lending ogency for � �.
ihe performance of the work for which this permit is issued PfRMIT FEE (Sub-Totol) 3� � � .�'• •4 2 5 0��
(Sec.3097,Civ.C.). � . .
. PIAN CHECKING FEE � ._ ,... O Z� C)�$Q __
lender's Nome � � �
PERMITISSUINGFEE-. - . /D SL� �
Lender's Address � � - � �� �
I cer�ify that I hove read this applicafion and state that ihe - TOTAL FEE y�',,sQ , _ - .
obove informoiion is correct.I ogree�o comply with o11 County � .
ord�nances and S�a�e laws reguloting EleUricol wiring,and . . �
here6y authorize representa�ives of�his Coonfy to enlar upon � . - . � � �
�he bove-j�' n�'/wed ro y f inspeclion purposes. � .
���1i�'1 / v't'��� SEE REVERSE FOR EXPLANATORY LANGUAGE , _
Signoture of Permittee Dafe �
' . , . . .
o z � o " ` o � � .
� � �
. ' �m D � C A C p
.�, � n D N � = A �
� �
- _ o c n � ° b . .
z = z p � o
.�
_ � o '° � � o �
. � � m m 7C m tn ' � �
v �
�
. �� �^
� ,
0
�
'�J D
� ' � �
ti
� �
N
�
, Z ,
' D .
• ' C .
- � ,
- m .
1 ,
� � . O o a° o . ! n 3 � F f oin�-. G•, vo a �.,rl�a o �'m= - '
' � N 3 F� � o r� • o °� w� o � o � c � m c n �.
� ' ' � � � -L Q'e �'' 7 7l`O N!1 p 0 N , ' � �� N � p �
' � N O 1� �� � m �0 > > .
f� x _' Otrn ��'cn on ''" o �n��'1� ^ =.N D o N � �-
' ' � . o b ° � c ° m M'N �� n o� o °�o� �.'� ' o 0 0 0 .
�-� _ o mo o= � � oM o o� � � ,.
� 3 � °•-�o �-� c: o�-;.�cm ° r-°v� m a � O{
` .. ' . �' S C � F N �p'Q O > > F,-:. �O O p,n N �y� � �O 3 G
, `� 2 � 'o � c3FN ° m'. v�° Ro � :,o ; + ° Z
' . . . W c9 S^n. b a�n _ .7� O S m
, ' � � C � C."m O m 0 � -�+. �^ � �= 0 , •T•,� � � m O A -
• . _ � N o� goa� N � m' ' � � � mN .-� o � oo - �
� . o � � � o � a� s N o 0 4� o � � o o c
� � � �.S p T'^ Oti � Q-m p b o � F L N �^ r- -
; 0'050' �'o ° n"v ° ° xa'n� _n7,a 'cof c� �m
� � c� �.� °v »°� o o ' 3 °,�'cv o`^ a�x � .
' 0.° �-�-o�c'^. o ; �roDb v° a � ' o°-1° 3 v
m
o �e F ? o w a<. b 3.'� �.a� 3 0'��o v n
. -- m °.° �b � � ��f'- m < <.a � �o° o„-`'�c ° S .
°,b °,� o ao a - �� o �,��o-•- � �' ' 3 D
o < o � � F � �Doo � o.ao' oo� ��b �c �
N f� p� h'3 � � T
, ' `�� o� o� soo �N � � � � '^.no ^ 2 ° Z
• � 3.;C'N a°.c f m o a� � o� o � o 0
$. �� n o ��'�"�-°-^ � m o� � y
. , Tj Qo 0 0 � � o N� ��N aa 3� V
_ m • w ° '"m � av° ' o'"o�O °.'" oo fwo
, . .. � . , a o° ° 7��~c' ^ n 2��� «• '�," 7 A c 0 j-7 i„p.