HomeMy WebLinkAbout1039A (9) � �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 '�
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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
� CERTIFICATE OF EXEMPTION FROM WORKERS - � `` FIRM NAME
:. Outlets:Rec�Lighl,�Sw.!�� 'MAIL �
. COMPENSATION INSURANCE A�DRE55 �r qf �� r�}�[}S.�. �Uf 1 ��
'(T hls sea}ion need no}6e complefed if 1he work involved by . -Tot�l Na. t�f Firsi 20� IS� \ j
�fhe permit is For one hundred dollars(SI00)or less.)� .
-�� Addilionoi ': � CITY-'�f✓7J��r� �rY�,�(�"`Tel.No. r:
�: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 �
. Ezempiion,�you should bemm sub�ect to �he 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 � .. . . f
� � Dat � 0-200 Arnp.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� Prafessions 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 outhorize representaiives of this County to enler upon � ��� . �� � � � -� � . . . �
� � ihe a ove-m� " e���...pppttt```dpe/ry for���'''i,,,))),,,spection purpo5es. � -� � ' . � � �
j�' ( /��` g� � /� ��� SEE REVERSE.FOR EXPLANATORY LANGUAGE
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