HomeMy WebLinkAbout1339A (13) :�. WO�iRERS'COMPENSATION DECLARATION 76n66] �o�e� APPUCATION FOR ELECTRICAL PERMIT
TI hereby af(iim fhal I have o terlificole of consenl�o self CE-&MG �
insure,or a tertificate of Wo�kers'Compensation Insu�once, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a�r�iOe i copy�hereof(Sec.3800/,+Lab.C.) A 1 �
P❑ol��cyNo. ��'� Compony—l7CA�AI /'tCCi(i�h,` FORAYPIICANiTOFIILIN JOB /�� Z j��amOapL �Y $I•
Certified copy�s hereby furnizhed. New Residential Bldgs.8 Pools EACH NO. FEE ADDRE55 1(.(/(p ,Y
�Ce�tified copy is filed wilh�q�n1y¢ui ding i peo- 1 8 2-Family,Sq.Ft. S = S LOCALITY ���y,{t�0y�� ��
fion departmen�. / l MVlti-(Omily Sq.Ft. NEAREST
� � � Residential Swimming Pools cRoss sr. St- fo55 i n
Date U1 Applitan��� J OWNER OR
CER IFICATE OF EXEMPTION FROM WORKERS' �,8 � � FIRM NAME ��I
Ou�leis:Rec_Ligh� Sw._ � �"u`�� s UAf �Y
� COMPENSATION WSURANCE �"�S a0 ADDRESS
Thl���cNen nNd net b�com I�f�d IF th�werfc Involv�d b r First 20
� � Y Total No.S� Additional CITY �n Tel.No.
lhe parmil Is for ona hundrod dollors(SI00)or le�s.) ' vtarv cr+eCK /�� G
I ce�tify that in the periormante of the wo�k for which this APP�IC.4NT NK.V �a� l.�«�i L
permit is issued,I shall not employ any person in ony monner �
so as�o become subjec�to the Workers'Compensation laws. ti9hting Fixtures� First 40 '7� r ADDRESS S � vp_�I I �'ZQ�
- Total No.� Addirional 2
. GN (,,�, Tel.No. rj'1�2SI>
Da�e epplicont Fixed Appliances Not Over I HP PERMIT I
NOTICE TO APPLICANT: If, after making ihis Certificote of APMiCANT a E YL�yic.
E:empiion, you should betome svbject �o the Workers' Range_Heater_D.W._
Companso�ion provisions of the Labor Code,you must forth• Oven _Dryer _W.M.— ADDRESS S[�( val( l• � �
wiih comply wi�h such provisions or �his pe�mit sholl be Top _FAU —W.H.— �IiY L,�, el.No. ��25�
deemed revoked. . Hood _Fan _O�her—
.. LICENSED CONTRACTORS�ECtARATION UCENSE OR (���Q C—IO
I hereby offirm that I am licensed under provisions of Chapter9 Disp. _Room Air Cond. — REG.NUMBER u Class. �
� (commencing with Section 7000)of Division 3 of Ihe Business . D�STRICT NO. PROCESSED BY �,:
and Professions Code,and my license is in full force and effett. Power Apporotus 8 lorge Applionces� �
�J Q, 1 $ize&Type HP,KW,KVA,or KVAR� O U
License Number ✓"��v Lic.Class �—r� FINAL �
I� Up to 1 Ind.
Contractor �� [G�� �J'Z ('C�� = Over 1 to IOlncl. DATE p� VALIDATION �h
❑ Date Over 10 to 50 Intl. FIN L W
I am exempt under Sec. Over SO fo 100 Inc. BY �
8.8P.C.for ihis reason �vef�� z
Date: Services,Swbd.,MCC 8 Panelboards� �
0-2W Amp.Under 600 V , -
�ignature 401-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exempiion fo.Reg.Moint Elect. .q� 3�J.(�A
$INGLE FAMILY Temp.Power Pole 8 Appur�enances
HOME OWNER-BUILDER DEQARATION i��• • • ��
�hernl.y..f{�.�..il...� �t.�. }I.e�'..�y�.�.,.:i�.e�.e Sign with One Branch Circvil
�°�T���T�,„_� Additionol Sign 8ranch Circuits �
Low for fhe following reoson(Sectton 7031.5, Bosiness and I � 2 9.�Q
Profess�ons Code): �
❑ I,os owner oi the properly,will do Ihe work and 1he Misc.Conduils 8 Conducfors • • � 2 9.�Q u
srruaure is nor in�ended o�offered for sole(Seu�on Othe�(See Comple�e Fee Schedule)_ , ��� O B.P 7—S b �
7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY .
I hereby offirm that lhere is a construclion lending ogenty for
the periormance of Ihe work ior which ihis pe�mit is isi�ed pERMIT FEE ($ub-Totol) �
�Sec.3097,Civ.C.).
PLAN CNECKING FEE � �
Lender's Name
� PERMIT ISSUING FEE �O �
lender'sAddress �� �
I tertify Ihot I hove reod this applimlion ond stale that the TOTAt FEE �
ove�nlormot�on�s corred.I ogree�o comply wiih all Counry
or � nces and SI ws reguloting Elechicol wiring,and . .
hereb authoriz repr sentotives af this County to enler upon
ihe o6 e�men�ion proper'y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��`� d-Z'7-8�
a
�gnorure of Pe�minee �ate .
. . `J -- _ ...- ;--'I+.. .I. .._ ._..i_ I ._.' `_i.. _.i
_ _ I__ � - ��. - � I ,.
, 1 . _ . ;
' ; _ _ - � - -. i.. . .
� • -
- - .. - , . . -... -;� �
_ _ -- . .. � '
- � - �-.
I ' • _' �Z T C R7 T C a] � -1� _..
! �O 7 :� � � K O Z "' -
� y - .� � C o � --
' _ I -- ;� -- s ' �; � = N � D •
_ • S o w � � ..
' ... i - � ° ; c o o :n . '
�.. �n m m
.. . � � �� � . . .
' . . '.. n.. .
. . .. .. . . . . .. . _ . � � . .
. � � . . . � . . ' _ � ]i . ' ;�� . � .
. ' ' . ' . � � " �\ '1 ' ,
� � .
�_' ' � . . _ . . -- � �' .
- . � � �, ' _ �� � �DR � • �. .
, � � . . ' ._ . r �� '
1 rn
i - - . .
i , _ � •_
i , � _ � .. , , , � - �� � .. •• , .
i.. - • : _�i '
. ' _. ". '�' . _ ' . .
. ' .. . ._ ' . " .. �_`' , � . .. .-
. . .. ' .. � �_ . ' � I
: . • . . � . � `__. •, . '
. , � , � . . . '. . - . , �
� � � . ' ! . ' ` ' " .+ • i
: � , . . . ' .. - . ,. . . ,
� � . : .
!' "' ' . .. ._ .j._ . ... . . _. . . . .. �....I .. .... . ,. .. . .. . . . _...._ .. ..�..........._.�....__ . .. ..... . .� '
' . . i - . - . . � � � �� . . .� . , _ .' ..
' , . - . � I � ' � . .' - : ; ' .'. : j''.. -.
' - . ! : : � o ro -o !�� �-o r��, ° o�•� ° I�9 `�"� � °n �3 ��a � c s � .
> > ! . o -.
. . � . . _ � � ry ; ' 'O .�� ' �7 � p-7�O'n o� ❑a' p V'�ry j C "� N'U i q N c � - ....
. . - � . � ; n . � ��o.�� Q3 ` � S:c'•'^a'�'o R"o =o' N ^� •- - -
_ _ O Q O N 4 . u�U �O n:l R�O .O O .
- ' , " .. � ' O ! ,D � f y � � O Ca O 0 n � �o�i.'�v.�.o �71.t _ :� .
� � . � � � . N . 7 T `-� w �o �'° � - _��b a-s.o,ro �-°_ 3 �c 3 :z ; " �.
' � • ' ' -�, < oa�� 2N ° � �VO � d° m � e� �sT ,n� ..
� - . - - • ' o � : ° on' ,moUco'o u .;o �-�flN �2oNo ° '� , • ..
oa� N � o „ �-noco _ v�
i • . . _ _ � �n . � ��-o aN o va-c ' �'� o a�v � '�,� � °3 C
.a o ' � ' .� o o.x i.,-.� n'a � �1 0 0 -
• . . Q �q zqoci., � '' � c r1.''. =; tof � r*+ :
- . , �o�o _� o'n m o 0 0 0 ��et� o"^ a5' x v .
' � � - ! - � � - . . ` ��.q C S T��<N.o n. `� j,b S� n n '+ 'm'u" � p � ' .. .
o � � 3 ,m
• . � � � � � i `. o•�`C ° � o' � ��," o '�'c �-m � 3 o D� �" (�
� . . � I. 'N. Q F 3 M O 1 � . � 1 d � �. ; 7 p � 11"
- ; . . . ' . . �-o_°. n� o � n�f• � � c m a��0 7 p a_�.,` � o '��- ' .
' • - _ ^u o' �' < aF o o p� o a-� � � o� a«'� `c' ' 3 �....
- ° � � s3FQ . � oo3N ' o' 000 -°° n� �O_, "
. •m� 3 a o �, -.n � e 3 � � �,� n � ,Z,
� 0 O l ti
� �am �ro`o n=
. . � � ' -� . . - ' . . ' ��.m�" R N ' � � � �a� � � p Q - . .
. _ . . , . � i ' ' �. �' O'II f . T � 0. � � ` 'q] , > . . . •
� . . . � .. ._ __ � - O ' _
. . . - " O� Q O u � O- C 0 N�,.5•ti D • 4�. < �
.. . .
. ' . .. , . �7 ] �.J N.O � � . 7 C � C O � � � O O F 0 p .. .: ) -
- - . , . . � � ' a T p_�7 n � n _,. � n�4 '��^. H,� 7�'J 7 S�V J ' _, -
.\ .�
. . _. . . . - " C C � � S`c . ' 2' 2 �. ] u . T ri � . . T- .. r
� ` _ .