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HomeMy WebLinkAbout1741A � WORKERS'COMPENSATION�ECLARP710N 76A663 ,a�e, qppLiCATION FOR ELECTRICAL PERMIT,S�p Ids' {� . I hereby elfrm tha�I have a cCrti(iCatO Of COnSBnt�o self insure, CE-806G or a cerst�cate of Nlorkers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY �� copy thereof(SenC.3800.Lab.CJ / Po❑Ilcy ND. �L� _ COmDa�y- ���/Y/� POR APPLICANT TO FlLL IN . ADDRESS S� N��I '`�f�JJ ���' {f'V�. �C rtified copy is he�eby fwnished. New Residential BId9s.8 Pools EACH NO. FEE rtilied copy is filed with the county buildirg inspection 7 8 2-Family,Sq.FL S — S LOCALITY����J,(/Q Q�� depariment. .. Multi-family Sq.Ft. � — � NEnHESt . flc,/ rTJ cr�oss sr. NSL'TS�%CRUSS/N� DaIE ��Applicant �`/'���`//� �esidenti2 S iimminp7Q{��Is OwNER Oft /^ �/� ' -�' ' f [ FIRM NAME [� E� ��/�"L CERTIFICATE OF EXEMPTION FROM NJORKERS' '.� � MAIL COMPENSATIONINSURANCE - . Outiels:Rec Ij9ht Sw. qpoReSS �S� ��.D/ HONJ LV,/�• .(This seclion�need not be completed it the work Invotvad by Ihe l Firet 20� - '� permit is for one hundred dollars(5100)oi les4.) � Total No.� qdditional . --� CITY �(�MQJ/����� Tel.No. I certily that in the performance Ct(he vrork for which this permit - �p P�arv CnECK � � is issued,I shall not empioy any person in�2ny manner sa�5 to .J � ����� �� -- ' - AP���M� �become subject fo the Workers'Compensation Laws. � L'ghting Fixtures�_( Frst 20 ADDRESS�� � � , Total No.� Additional � Date' � -Applicent - � - . GTY . . . . . Tel.No. NOTICE TO APPUCAM: It, after making this Certifieate ol Fixed Appliances Not Over 1 HP l� PERMIT ,r Exemption,you shoutd become sublect to the N,brkers Compensation Rarge_Heater_ D.W. _ nt'auCnM G^ provislons of the labor Code,you must forthwith domply with such Oven_Oryer_ W.M._ - - � ADDRESS L�3 ` q /� s'�. � provisions oLICENSED CONTRACTORS DECLARATION� . Top _FAU _ W.H._ CITY (�MONI�. - . ... Tel.No.�a �y Hood_ Fan _�Olher_ I I!C'Ch��l��rm'�F��I am Cxnsetl unddr pradsions cf Chapter 9 - �isp. —Room Air Cond. _ ucetisE oR p/ C��% ��(commencing with Section 7000)of Division 3 of the Business and � � � � nec.uuMeEa D��, p/� C f d � Pro'essions Code,antl my license is in lull force and ef(ect.- a57ftiCt Na rnOCESSE Y Power Apparztus 8 Large ApPliances 1 � � ^ ��/� /� ,^ Size 8 Type HP,KW,KVA,or KVAR � . � J O�� License Num6er r�-7� , Lic.Class� Up to 1 Incl. � �-- FINAL U � K�`/v.��IEIN � pate- �31Y. �r 1 to 101nc1.��, DATE D.->�� vnuoanoN � - ��Contractor — ❑ Over�10 to 50 Iricl.- - + �� . `,� ,7�1 A 1 am exempt under Sec. Oeer 50 to 700 Inc. BYA� W ear.a iar m�s'reaso�_ � o�too - �`• • • ° •� c4'n . .Services.Swbd.,MCC 8 Panelboards Z .-. . Date: 0-200 Amp.Under 600 V � � - � • •6 8,5 p Signature . .201-1000 Amp.Under 600 V . vo6E50� ❑ � � � - . .-. . . . Ovei 1000 Amp.w Over 600 V Exemption for Reg.Maint.Elect. �O 2�—�� � �- � �� � S;N.GLE FANILY . Temp.Power Pole 8 Appurfenances H0�9E OWNER-BUILDER DECLARATION Sign wiih One Brench-Circuit � - �� �- � � I hereby 2ffirm that I am e*empt from the Contractor's License Law f�r fne s�n,.,..�„�.e��,..,ice...:,,,,�no�c c Additional Sion Branch Cirn�its 1 , .��:............e a..�......:,._.. _ ._. ..._._.._.....�.__'"' ............._.,......,.,.....�.,....,.......�. Code1: .. _. . . .. . . .. .. .. . . . � .Misa Conduits 8 Conductors . . ` � � 7�0� I,as owrier of the property,will dv the vrork and[he structure � is not intended or olfered for sale(Section 7044,Busir�ess Other(See Complete Fee Schedulo)_ �. . , ,� and Professions Code). - � I • • e_�� CONSTRUCTION LENDING AGENCY _, . I hemby allirm that there is a construdan lendirg a9ency for the � �� • p^y�,`(�� performanCe oF the work tor which[his permit is issuetl(Sec.3097, pERMIT FEE (Su6-Tota�) Civ.C.I. - . . . .. .. . . � :'.2� —�� PLAN CHECKING FEE Lender's Narce .. . . . . . . _- ... . .. . . . PERMR ISSUING FEE !Q Lender's Address -'� - �- �' . "" � --�- � - � � , I certify Ihat I have read ihis application and state that the above TOTAL FEE in}ormatbn is correct.I agree to comply with alt Cwnty ordinances � � � - . .... ._ .. and Stato laws regutating Elecirical wiring,and hereby authonze ��,�0 mpresentatives of this County to enter upon the above-mentioned � -��� --�-- - - � -�- . . ._. . ..... _ property for inspectipn p rposes. � � ' � SEE REVERSE FOR EXPLANATORY LANGUAGE �- ` ' y-�/-S?f _ Signature at Permitt8 � �ate .,,�.-,. j i ..• . L_.._.�' �.... _. ... L.. �l_' " __ _ ' '� i .--- "_� '_ ._ __'._i l \ 1 r, �I . � i i � i ^ _ i �.. �.� / �'1 ' I I I i � � �.' � �' •1 �/'v�'' ; I i � i . . � i i � � .� . . - 1'� I �� fl i I • , , I� ( �. .� � I ! I � � ; ., � �: \.. � - 'l '.: � � � ! _ � , j . ' ;' �� f:,'a ` � ' � , ' � " I,. � \ � ti ' I`♦ ,�; i �I . i . i i� � i•. i i". i _ � �. i� — '- -�\ 1 � j �.. I i i i , i ; . . 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