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HomeMy WebLinkAbout1742A 1743A � WORKERS'COMPENSATIONDECLARATION 78A883 ,o�e, qppLICATION FOR ELECTRICAL PERMIT C� IO I herehy affirm that 1 have a cerlificate of consent to self insure, Ce-e06G . �v[ or a certiticate of Workers Compensation Insurance,or a certificd COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.1 /�t ,/!1 � 10�j Policy No C � �omparry TGT/�'�1 FOR ACaUCAM TO FllL IN .we..... / /,� ❑ Certilied copy is hereby furntshed. New Residenlial Bldgs.8 Pools EACH NO. FEE ADoaeSS�,'� f0 /�• b//i r�o�� f� �' yJ . . . . � 1 8 2.FamilY�S9.Ft. S — S LOCALITY ��/� �� ��Certified copy is fled with the�county building inspection _ � NeAREST �,/ /� ,//' . depaftment. . . -�/' n t MUI1F(Zmily Sp.Ft. CROSS ST.�� U/v SC �J)�N17 D�te �`l-�t� ��Applicant KE�"�/�/L��/ Residential Swimming Pools �--- - pWNEH OR p�// � IO -l� F�RM NAME- � /J N4' - � ,- CERTIFICATE OF E%EMPTION FROM WORKERS'. �� � Mni� C AD p� - COMPENSATION INSURANCE Outlets:Rec L'ght—Sw.— � I[' O ADORESS `JG �• MC�O iJnR/aGYI - (Thfs sectbn need not be oompleted It ihe work Involved by the �CJ First 20 � permit la for onq hundred dollars(5100)or lesa.) - Total No.__L— Additional CITY � �,�/� Tel.No. .I certify�that in the Oerformarxe of the work for which ihis Dermit . . _ . A��Cq�K .. _ is issued,I shall not empby any person in arry manner so as to � , Oecome subject to the Workers'Lompensation Laws. � L'ghfirg Fixtures Frst 20 . � � � A��RESS. .. � , . � . � � � Total No.� Addition2t _ ., CITY� - � � - . Tel.No. Date Appticant � Fixed AOP��ances Not Over 1 HP ' _N0T10E TO APPLICANT: 11, after making this Certifieate ol PERMIT E��/)//-y-. � Exemption,you should becoine subject to Ihe Workers'Compensation Range_ Heater_D.W. _ nap��cnNi r� Ii/ .provisions ol[he Labor Code,yo�must forthwith comply with such - Oven--_�ryer�_�W.M._� ' ��� � �' � ADDRESS y� y qrN sr• - � � �- .provisions or this permit shall be deemed revoked. � Top — FAU _W.H.� - � LICENSED CONTfiM1CTORS�ECLARATION� Hood—Fan _ Other_ � CITY ('jr-f U.✓Ij � 7e�.No.G�'J f/S�n-' I hereby af(irm'that I am Iicen=_ed und=r provisions ct Chap;cr 3 __DISp. _ROOm AiI COnd. _ LIGENSE OH Q'� Ciass G b � (commencing with Section 7000)of Oivi5i0n 3 01�he BuSine55 and-� FEO.NOMBEP p Professions Code,arid my license is in full lorce and eflect � power Apparatus&Large Appliances DISTRICT NO. AROCESS av _ .._.. ._ �� Q �1 b . C/� Size&Type HP,KW,KUA,or KVAR U License Number d�3 O�/ Lic.Class - �� � UD to 1 Incl. ,- � � - - �� - - - FlNAL � �- I/ c ) ((� Over 1 to 101nc1. DATE /D� VALIDATION O � Con[ractor/�f+� Cp�l�Tl/� ��- Dafe `���v' Over 10 to 50 fncl.� � �� FlNAL � (~j ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W _ n. ._.. _ . o�.,00 BBP.C.for this reason � tq � -Services.Swbtl.,MCC&Panelboards - - � - �� � ;� 7�.2 i1 � Z - � Oate: 0-200 Amp.Under 600 V Si9nature 201-1000 Amp.Under 600 V � - - - � � �� � � � �2 ❑- - -�-� � � ���-- -� Over 1000 Amp.or Over 600 V . � ExemGt�an foi f7eg.Maint.Elect. ... . . . . . . . . . � • °�G�.C/n -�-� � � ��� �-gLyGIE FA.".".!LY� . ��� � ' Temp.Power Pole&Appurlenances HOME OWNER-BUILDEFi DECLARATION � -Sign with One Branch Circuit� � � � �� ' ` °G�,l��u I hereby aHirm that I zm exempt from the Contrector's License Law for the followirn7 mason ISan�nn 7031 5,g�,ic�,��a a�,n?.:!°e�!pr.s Adtlitional Sian Branch Cira�ts . - O 9.P�-8 a Code): � �: . Misa Conduits&Conductors -. '-. - . .. ...... . .. . . . ��?�J� I,as owner of the properry,wiil do the work aM the structure Other(See Complete Fee Schedule)_ is not(ntended or offeretl for sale�(Section 7044,Business , tt s s . e o'� and Professions Code). � - ����� �� � - � � � CONSTRUCTION LENOING AGENCY � � � � � ��-� -- �� � . . . . ., � '.' � �S n I hereby affirm that Ihere is a construclion IeMing agency for the � � performanCe o�the work for which this Oermit is issuetl(Sec 3097, pERMiT FEE� � � (Sub-Total)_ .. , ` � �^r��� Civ.C.1. ' � .. PLAN CHECKING FEE . � � .. ��'2� -�� Lender's Name ' PERMIT ISSUING FEE I� Lentler's Address I certify ihat I have read ihis application arM state Ihat the above TOTAL FEE � 3 information is corred.I agree to comply with atl County ordfnances � � � � . . and State laws reguiating Electrical wiring,and hereby authorize � . representatives of this County to enter upon the above-mentionetl� � �� - � - �- - � � ' - � '' � - � - � , - � � property for I spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . .. . . ._ ... . . _ 9'-�1��8 . _ Signature of Per -,lee Date ��� -,�,,:.• . , . . a• ...1'.'•I.J 1..�.. � � �._ l �L�. . _ ___ ;_ � .__,�_ _.._._.i_�__._.;.__,_.....�-.-i^j l ;': �_ I : � �j : � ! ; ; � -. �_ ,� � : , ; 1 , � i -=, �c. — �•- ` �! ' ' � � 1 ' I � i I � ii � '-1"': . ' � � � i j I � � ' . � ��� ' i � •I � � I 1 _ i � 1_•'- 1 r �7 _ . -. j ;. i ' _ � 1 j _ , � ; : � �,.� � �' ` � � � � - � �'" � 4 _., ,�� � i I' I � i i I -. . �''� 1,,_ �� � 1� . � , , i�' • - - - � � . 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