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HomeMy WebLinkAbout1408A (13) . . . . . . .. . .. .. .i . . . .-' �..� � . . ._ . _ _ '. .' _ . . . . . . . � � WORKERS'COMPENSATION�DECLARATION �- 76A663 ,o,a, � �..p,pp��CATION �F�OR�-ELECTRICAL �P.ER�MIT�.� .� �� . I hereby affirm that I hove a certificate of consent��o self �CE-so6G . �.�insure,or a cer�if�w�e of VJorkers'Compensation Insurance, . �� COUNTY OF LOS ANGELES� � BUILDING AND SAFETY- - � � �or a cejrt�ified topy thereof(Sec.3800,Lab C.) y� - - - � ,� ' � ' . . ��..P�olic�No. �o"�� Compan���'��'�� 1sLJ1z:�ld��/ - �FOR APPUCANT 70 FILL IN� JOB _ Certified copy is hereby furnished EACH� NO. FEE ADDRE55 1��P ��� New Residential 81dgs.8 Poo{s LOCAIITY � - .�Cenified copy is filed with ihe county bu�iding inspec- 1&2-Family,Sq.ft. � — $ � ��� �i � t�on d portmPni. . � Mulh-family Sq.ft." — NEARES7 � '"� y �" . CROSS ST. �° �� � Date�.��_Applicanf�J.___L'__: .• IA.�/ ResideMial Swimming Pools OWNER OR , � � - FlRM NAME� Y�)i/y ,.-" C''. . � CERTIFICATE OF EXEMPTION PROM WORKER5 � Outlets:Rec�tight�Sw.� -MAII � . - . COMPENSATION INSURANCE � � ADDRESS ' J� ��'L,�� - !, v jThis sectfon need not be completad if 1he work involved by �J,. First 20 � _ � To�al No. . a''�.� Addiiiona� � � CITY��t� Tel.No�'; t, ��1he permif is for oae hundted dollars(5100)or lass.) piqN CHECK I certify thal�in ihe perTormance af�he work for which lhis � APPLICANT - permil is issued,I shqll not employ ony person in any manner � ' �so as to become subject to rhe Workers'Compensation�Laws. :.lighting Pixtures First 20 d� ADDRESS z Addilionol .� �.�,�1���'�� Total No.� CITY Tel.No. �. � .-�Date�.1�.�..Applicant '��.Fixed Appliances No�pver 1 HP peRMR � , �N0710E TO APPLICANT: If, after making this Certificate of � APPUGANT,� ` Exemption, you shoold become subjed to �he Workers' � Range Heafer_D.W._ � - � :��Compensolion prov sinns of tFie Labor Code,yoo mu5l�forfh- ' Oven Z Dryer —W.M.— ADDRESSi "' �"�, ,��.,.' h wiih compVy�wilh such provisions or this permit shall be � .Top FAU —W.H.� ,i � i; �I�deemed revoked. � . . � � � CITY n Tel`No. .1 ° � UCENSED CONTRACTORS DECLARATION ��� Hood �,Fan �Other_ ���114�.- � �'� :4t-3�,� �., . � Disp. L Room Air Cond. — '..C�l���ENSE OR i , Class. yy 3� I here6y offirrn Ihat I am licensed under provisions of Chapfer 9 REG.NUMBER ��' �y�- � � (commencing yrith Section 7000)of Division 3 of�the Business :. �power Apparatus&Large Appliances DISTRICT NO. PROCES$�D BY .� and Professions Code,and my license is in}�II force ancl effect. , �` rE d � ����� � Size&Type HP,�KW,KVA,oi KVAR � �� �c.�–�Ww� ` ��License Num6er-����'L.L.�-Lic.Class ,�_�2_� Up to 1 Ind. FINAL �. ��� ! � � ��` �'-�.���' .,.� y ,��. Over 1 to 10 Incl. . DATE 3 �� a VAIIDATION ����.� Contractor Date Over 70�0 50 IncL FINAL � F '� �,❑ I pm exempt under Sec. Over 50�0 100 Inc BY {�� . ���-^ � a i.. �. B.BP.C.for this reason Over 100 � S V� `='-�'J�"� � .y . (s � - Services,Sw6d.,MCC&�Panelboards �� � [� e: k � 7 0-200 Amp.Under 600 V ���L �`.� •.� . Signuture 207-1000 Amp.Under 60p V-`� � d� � ` � x.. °'� �� Over 1000 Amp,or Over 600 V �`;� '��� ,� Exemp�ion for Reg.MQint Elect. � �:� ' �' SINGLE FAMILY °Temp,powar Pole&Appurfenances $� . HOME OWNER-BUILDER DECLARATION � - � ��� � �� �Sign wiih One Branch Circuii ��i ��0,8 A 4 I hereby affirm that I om exempt from ihe Contracto's License 'qdditional Sign Brpnch Circuits ��.. _.�, law for the foliowing reason(Section 7031.5. Busines nnd €: . . �%a a a a,o� �M r"rote5sions CotleJ: � �,;- �, .❑ I�,as owner of the property,, "II do ihe work and the �Misc Conduils&Conducfors �r - t y, I L 2,�Q �Y�. �'� structure is not intended or offered for sole (Section `Other(See Complete Fee$chedule)— �n, e f�,.. .� 7044.Business ond Professions Codej. . � ° � � C: �(�(�t � � CONSTRUCTiON LENDWG AGENCY ��U 7...�(� �� � - � I hereby affirm}hat ihere is a coqsiruUion lending agency for . : w�� �the performance of ihe work for which fhit permit is issued PERMIT FEE (Sub-io�al) /f7�S ��� ,�. (Sec.3097,Civ.C.). - , � . .,,�. ":,!'':� PLAN CHECKING fEf � lender's Nome - • �� Y`� PERMIT ISSUING FEE O Q9 �. �i: Lender's Address , - � - �' I cerhfy thar i have read�his applicmron and state tha?the TOTAL FEE (�„�. L''� � e. obove information is correct:I agree b comply wi�h all County . � ' ordmances and State laws reg�loting Elecirical wiring,and � �'_� hereby ouihoriz eseniptives of this CouMy to ente�VPon ; � tha above-m ione property for inspection p4rppses. SEE REVERSE FOR EXPLANATORY LANGUAGE � � , ,r,i' � � � 3 �.�:� Signatu e of P� ittee �te .;. 1 ,\ ` \� ; \ \ \ \ � � � p G � \ � ,��� q d � , � \ �:' '{ �. C, � �y' `� � �fi Z r � � �z � ` � � � \ d����� ��n� �� � � � \\ \ � \ \ u' �\�C,` G �}O in \. \} \ � \ ` � , �2\y�' � '` T 1 \ \ ` \ � � � .� ` \� 5 . i . � ` . : \y � t�"�� . � fl 4 \ ` \\ \� �'..� \ C� \ � . . `��+- ' r.-�.I �T \ \` i� � m � � �, \ �- \ ` \� � `. , � � . ,:�'.. 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