HomeMy WebLinkAbout1728A (19) WORKER$"COMPENSATIONDECIARATION 76A663 10iB1 APPLICATION FOR ELECTRICAL PERMIT � �
I hereby offirm thal I ha�e a cenificaie ol consent to self CE�806G .
insure,or a certificate o4 Workers'Compensoi�on Insuronce, COUNTY OF LOS ANGELES BUIIDING AND SAFETY
or a cerlified copy Ihereof�Sec,3800,Lab.C.) Y -
P❑olicy No. 3•�b7�Company S'�'y�G�l�U+�N FOR A►►LICANT TO Flll IN JOB r
Certilied copy is hereby furnished. New Res�deniiol Bldgs.8 Pools EnCH NO. FFE AooRE55 -�G 7 �� 2� .��
� Ceniiied copy is filed with the counry building inspec- � 1 8 2-Family,Sq.Ft. 5 — S LOCALITY �� �
tion deparlment. Multi-iamily Sq.Ft. — rIEnREST
Retidenliai5wimmin Poos CROSSST, S;JWS , � )SS„
Do1e a1-$-��Applicont �j��('rl r OWNER OR • ( j /*� �
� FIRM NAME p+ / (��, /
CERTIFICATE OF EXEMPTION FROM WORKERS' p� mnu �
COMPENSATION INSURANCE Outlets:Rec�light_Sw._L_ `� � ADDRESS6 '�OIJ /� �
(Thl�tocFlon nesd nof b�complN�d if th�work involv�d by Firsf 20
fh�permif is for one hundrad dollars(f100�or les�.) Total No. �� Additional � CI7Y /� Tel.No.=/3 G�y'�js
I cer�ify lhat in the performance oF Ihe work for which Ihis APMICANTK
permit is issued,I sholl no1 e�p loy any person in ony manner
so as to become subjecl�o the Workers'Campensation Laws. Ligh�ing Fiatures First 20 ���SQ ADDRE55 �
To�al No.� Addilionol
/� i�' CITY • Tel.No.
pote ..�.b_Appliwnt��l�L Fixed Appliances No�Over 1 HP PERMIT �
NOTICE TO APPUCANT: If, oi�er mok�ng this Certificme of R�PLICANT � 3'/ ���' {/'�� �
Exempiion, you should hecome subject to the Workeri Range�Heater_D.W._
Compensotion provisions of the Labor Code,you m�st forth- Oven �Dryer _W.M._ ADDRESS ,v� y7�
with comply wi1M1 su�h provisions or Ihis permil shall be Top _FAU —W.H..L
deemed revoked. � Hood _Fan _Olher_ CITY , �� Cy�, al.No.5 S
LICENSED CONTRACTORS DECLARATION � uCEnISE OR
I hereby affirm Ihot I am licensed under provisions of Chopler 9 �Disp. _Room Air Cond. — REG.NUMBER �{ �7Js Closs.[—(d �
(mmmencing with SeUion 7000)of�ivision 3 oi the Business power Apporatus 8 large Appiiances � � �-� - DISTRICT NO... .. . .. PROCES Y� n-� -
� and Professions Code,and my litense is in full farce ond effect. f� U
ySG 3J(� Size Type HP,KW,KVA,or KVAR V
license Number / Lic.Closs ���b FINAL , �
Up to 1 Ind. �
' I./y,f._��/ ��� �_ Over 1 ro 10 Incl. DATE [�C�� 4� VALIDATION V
CoNroUor �Da�e Over 10 to 50 Ind. `
❑ FINAL W
I om e:empt under Set. Over 50 to 100 Inc. B „'f� a
B.BP.C.for�hiz reason �ef�� vJ� Z ��
. Services,Swbd.,MCC 8 Panelboards � �
DO}e' 0-200 Amp.Under 600 V .'�-. . .
Signature 201-1000 Amp.Under 6W V �
aOver 1000 Amp.or Over 60p V
EKemplion for Reg.Moint.Elet�.
SINGLE FAMILY Temp.Power Pole 8 Appvrlenances
HOME OWNER-BUIIDER�ECIARATION Sign with One Branth Circui� $ s
1 hereby offirm thot I am eRempt from the Contractor's ticense Aedirional Sign Branch Circuits � 4 1 �i 2 8 A
Law tor the following reoson(Sec�ion 7D31.5, Business and
Professlons Code): �
❑ �t. • • ••�
I,as owner of tha property,will do ihe work and the M:sc.Condui�s 8 Conduc�ors
sir�c�ure is no1 intended or offered for sole(Settion Other($ee Complele Fee Schedule)_ , r •�3 ri B 5 0
7044,Business and Professions Code). . • •3 4 8 5 0 c=i.
CONSTRUCTION 1EN01NG AGENCY
I hereby aFFirm thal lhere is o conslruclion lending agenty for • Q 9�g..$6
fhe perfo�mance of the work far which ihis permit is issued PERMIT FEE - (Sub•Totol)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE � "
Lender'S Nome �
PERMIT ISSUING FEE 1Q �
lender's Addrezs �,I
I certify iha�I have read this application ond sro�e Ihal ihe TOTAI FEE t•�
obove information is mrred.I agree fo tomply wiih all Coon�y
o�dinonces ond State lows�egula�ing Eleclricol wiring,and . ,
hereby au�ho�ize represenratives of this County�o enier upon
the obove-menrtoned properry for inspection pu�poses. SEE REVERSE POR EXPLANATORY LANGUAGE
' r'j"��.6
Signoture Cf Permitt e , Date
y. .
' . ' � �
_ • ' . 5\ ., /. ! �:'� .
.�/ .J` .i - . ~L 1,A _ .
:� � � � .
,1• .l� i.}�,�� , � , , •�, / `.� + . ' �.y . - .
. 1 , �� J /� , . ' � .
' %".1 �t �- �. �' A' G '*'.
' :)' •, �, !fi - .r Z.•"O Q yo ,
�� � �)� -c, G O x� "' GG1 � �:;-rr.
". /.. ,', �,Z- .Z ' �� � G� x � � �t' . ,
�'j� ��� :J tt..� O 9 '-C � N � � � �G ,
i .,f, Y x � '�p
' �.-' \�''^ ' p � � a O O v+
: ' ' � !n., �� �(1 O � � i� �^ ' -
\ � - �'�' � �
T � \' �.
. C�,/• .(� ��\I . '� d �
C `' ''� �r ,v , .
t �,� '``�' ro M � o
�
/� ✓� - C.l• . . �� � .
, . J,, '1, .`�/r� �/ �� �:1` '�, �� �� M ..
� =C1� ✓� � �o ' '� ',r _ ,
1`.,ti� � _ �1 !- , N .
� . �� � `, � � �� y� • '
- , `�r'. ` . Q t �. mu ` •
. ` . � �/ �./ : .
. '� ' �ti' � . . '
�., . ' .. . . . ' • ` , .
_ • ' . . ' �-� , . . .. ,
.``• \ � ' '.�a � ._ . . � r`�.i ., . . ,
_. �._ '- . '. .. ' . .
i 7.' � ` ' • . • � . , .
, - `i�
i = � .
• �\ f� , ' _ � ' .
� . � ./i � ' . ' �
'1 . . . � � ' , ' . . � ,
� \ \ . , � . � . . _..- '�� � .
\ " -
1 , . , . _ . -- , , .,' .
' . . , �. .r,•� - . .
. . . . . _ ' n O Q Q m � - '. .
v' ^.O Q ". 'G � p QQ- .
�'� ' . : � D O O y�� �N p�0 �' < .. .. � .
r y- �..';.W�. '��'�U p ^'?�Q Q 0 �;, �Q � .
�, ` , o v, -n an? na'�y a 4 = .�� . ,
�� �t T � N G'o ,a o C 0 0 �1.� ?
` �, r� 4,c „ �.° ,_pcUw�-< o„�UMa;K30 � 's 'A
� c ;- C� � o
C� !�Q 6 " n a.3 [:.M � ., o•o::•yc.`�� Q a c a c� �' � ' �
� 'f. � — ° " " �;'o �, G
�` O � . � � �ff � ^ N N y � N 9..'.. �„�n�"C1 L^1 �^ � ^ f� O p Q� r . .
? l0 [ 'C5 '.m M n '� � Q
� m .� ':.� . o w� o ..«o a� 7 � . �?,.x �'` r-o ° a N M o t" -
, � ', �.,� ^ .,. ,ty ^.2 Q o;• p � 6 o N. n a.,� ... (�4 o A - .
; ' c,� . � , .Ly v � tMO �� o�, ;'p�•/���9 Q��4 ?'0 ����. O� .
- . `�� � c .oc.00.a.oM� os °.00 " "f+�v ° ' v ,n--
w o
. . � . � ' . .. -. . N ':a- �. 0 P�� Q m Q 'q 0,Q�. 7 � y �..�O CJ Q q? N _,.. � ' _
O 7
P- O
. _ . � . � . . . . a^ �� � _?�V �pv G O q ���?n �O L N..3 ,^-�� � r"� .
. . . � �� p y, ri cF _ '? ...�'. .Q .
' . : � , . i . � i � ,. n :O 4 0 �.c C� < o :^-�'� � � < � � „"� �p c A�o� �i'Z .
. G C' " � U 7 C.:. � "_ O.^ p� p Q ,< n ^
S a
" . . , . . . . . . c �� p� _ a h����. .S c o� w�� o �, � n � o o . _ .
. . . '. .� � o f 3 � n Q �`,•,�m Q n N o �� m:,a o " �
` •4; �m o'� `o o"��'O � , �'.^.° `n.� �.a `° C�3" 09
. ' . . , �o.A O � �.� � P S t`�'�G w O O-.. u� ON tn p ? r O `
. - . . ' "'O n~ A-. "� n •� �T � �tO O �,N c7�s
_ , � . � , � . � . 'p c O ?�O ��n '�t���? tD @ W ^Q � b �'7 S'
O O �C V
� . � 'r 7 3 �� p � SG�
. . . ' , . ' .. ' . � O ��jy.G N �.� O � �'� p.a �: S m
, _ . . .. . . . • � ? .� �' O �n � �.� 9 i0 _. 7 in
. . _ ' . . .. � O O„q u N n 4' • .
. ?� � � � � b,
. ' . _ . ' . 9 � O �"�C
• - . . , , , .y6 O �
, . ' 6-
. . . ". � .. ' . , i
l • " � .. . '. ' I'/��
. �' ;