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HomeMy WebLinkAbout1039A (7) � �I WORKERS'COMPENSAiION�-0ECLARATION 76A663 10/87 qpp`OCATION FOR ELECTRICAL PERMIT �� ��etl �i hereby affirm Ihal I hove a certificate of consent to self CE-806G '� ¢ s" msure,or a cehifimte of Workers'Compensation��sura�ce, COUNTY OF LOS ANGELES � BUILDING AND AF TY .or o certifyie�d cop ther�f(Sec 380yD,Lab.C.� .y � ��� J��� y�. � �` ��Y No�'��s Company_7��-�wfw� FOR APPLICANT 70 FILL IN � �JOB � � Cerfified copy is here6y fumished EACH NO. FEE AD�RESS � � r . New Residenliol Bldgs.&Pools J � � Certified co ls filed with ihe count buildin ins ec- � 1&2-Fomily,S Ft. '$ — $ �OCALITY p��n �y.�, Z � t` PY� Y 9� P 4� �� �G� ?� €Jl�!d`�ZdM�- �ion department. � Multi-family Sq.Ft. — NEAREST /� �'� ���/ {y� ,j�;� � ceoss sT. r,C g �� � � Date - Residential Swimming Pools �q / � ' ` Appi�cant „_ . - OWNER OR ��+N�`_ - 1 7u L�i�i��r f F�RM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS .. Outlets:Rec�Lighl,�Sw.!�� �MAIL . COMPENSATION INSURANCE A�DRE55 �r qJ �� �}�[}S.�. �Uf 1 �� '(T hls seaTion need nof 6e complefed if 1he work involved by /�� First 20� �.�� j �fhe permit is For one hundred dollars(SI00)or less.)� . -Total No._�4� Addilionoi ': � CITY-'�f=✓7J��r' �rY�,�(�"`Tel.No. �: �:I certify thot in ihe performpnte of the work for whith this PLAN CHECK �permit is iss�ed,I shall nol emp�oy any person in any manner � � i APPLICANT � � so os to become sub�ed to the Workers'6ompensaiion Laws. �; l ghting Fixtures rl First 20 ADDRE55 E � TofGl No.,� Additional " t Date Appl cant CITY Tel.No. � NOTICE TO APPIICANT� If nfia. �.,nL�,,., t6�� ro.�;F�..,.e „t Fixed Appliances Nof Over 1 HP PERMiT � . Ezemption,�you should bemme subject to ihe Workers' Range_Heater_D.W. — APPLICANT �7'��tj.�, �'�'��'�'�¢�f.. �� ; Compensafion provisions of the La6or Code,yoo must forth Oven _Dryer _W.M.— ADDRE55 7L� �dl''�"f� 1 , � � with com I wrth such I Z� '�J` � � � py provis�ons or ihis permit shali be Top _FAU � W.H.— � .f 'deemed revoked . � � Hood _Fpn ���Other_ CITY G jj�� �•�— Tel.No.�C�-���y � � LICENSED CONTRACiORS DECLARATION � Disp. _Room Air Cond. — Q�iCENSE o� � ��r� Class.q— � ' �I hereby affirm thot I pm licensed under provisions of Chapter 9 � - REG.NUMBER �? F� � '� L, � -� � i mmmencin pISTRICT NO. PROC SE�BY ( g wilh Secfion 7000)of Division 3 of the Business. �' power Apparatus&Large Appliances � � ' and Professions Code,and my license is in full force and effett � � y �� ��/�Ir// l . l� �`)� Size&Type HP,KW,KVA,oi KVAR� � �CJ y � License N 6er r Y Y y` Lic.Closs t � � � �I { p� j / (;l� .Up to 1 Ind. - � FINAL 63 � Confractor��j��i� Y�.��-l�r�te / ( �-' t�`! �'��POver I to 101nc1. PC� DATE VALIDATION � �� �❑ �. . Over 10 to 50 Ind. PINAL . a' �u I am exempi under Sec Over 50 to IOO:.Inc� BY � �f Over 100 -����� ��- 8.�8P.C.for ihis reason � • yg ' ,� , ` s '.� . . . � . � ' . � ���. � ' Services,Swbd�,MCC&Panelboards � .. . . { � � ., Dat � 0-200 Amp.Under 600 V Ol� �� . .. � .. Siqnot�r 201-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 6D0 V/jtt� A(!O CExemption for Reg.Maint Elect. - , , � SINGLE fAMILY . , �. Temp.Power Pole&Appurtenances .,; G�.0�. � HOME OWNER-BUIL�ER DECLARATION . Sign with One Bronch Circuit I hereby affirm ihat I am exempt from the Controctor's License� �+'� ��2� Law for the following reason(Section 7031.5, Business and � Additionol Sign Branch Circuits i� Professions Code): . � � � .. .� . j�r.(y/r 4.5�i . . ❑ I,as owner of the property,will do the work and the - � Misc.Conduits&Condocrors � -. -�� struciure is not intended or offered for sale.(Sec�ion .. Other(See Complete Fee Schedule)_ ?► .� �4-�i� r��.r.. . c� i. 7044,Busihess and Professions Code�. �__ . ' �� � ��� - - .� I � � CONSTRUCTIDN LENDING AGENCY . � G L 1��i F�i�l� � I I hereby affirm ihat there is a mnsirutlion lending agency for , . . � � �� � ; the perFormonce of the work for whith this permit is issued � � PERMIT FEE (Sub-Tolal) � �'�: - � � � � (Sec.3097,Civ.C.). � � � . . . . . . . � � - . . .. I � � � � PLAN-GHECKINGFEE � � �� � � � � � Lender's Name - - � � �� ��-� � � �� ���� � � ����� � ' � � � Lender's Address �� PERMIT ISSUING FEE . . /O 9... . . . , . -� ' f I cerlify fhot I hove read Ihis applimtion qnd state ihat Ihe . TOTAL FEE L�s���� � � � . � - above informvtion is correct I agree to comply with oli CouMy , , ' � - � �� � � . �� . .. � �. ordinances and Stale.laws regulatinq Eledriml wi�ing,and� � �. � - � � � � � hereby oufhorize representalives of fhis County to enler upon ��� . �� � � -� � . . . � � � ihe a ove-m� " e���...pppttt```dpe/ry for���'''i,,,))),,,spection purpo5es. � -� � ' . � � � j�' ( /��` g� � /� ��� SEE REVERSE.FOR EXPLANATORY LANGUAGE �� �..,. Signat�re o Permittee- � � . . �Dote� � . . � � . . � - � � . � . %. � � . . . . - . . ' ' . ' . � . - . . . � - � ! \ ' �,� \ \ � - �=c=�y s ; ,\ , V .n "a ? m �, c�+ � o � � � N 0+�� .0 C O tl �'� .Q1 .SY- �` . .. '� }� Gl D'V L G w l✓ �'O�.,N-.-� p-c7s N ' �\ . " . � � � �_4 � O �w ry � C . . . 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