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HomeMy WebLinkAbout1584A 4YORKERS'COMPENSATIONDECLARATION �6A663 ,o,B, qppLICATION FOR ELECTRICAL PERMIT � . � I hereby affirm lhat 1 have a certilicate of consent to selF insure, CE-BO6G «a cert�iica,e of Nlorkers'Compensation Insurance,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy[hereof(Sec.3800,Lab.Q) �j/ . �a. Policy ND. ' Compa�y FOH APPLICANT TO FILL IN . JOB ADDRESS ❑ Certif�ed copy is hereby furnished. New Residential Bldgs.8 Pools Ef+CH N0. FEE � Certilied�Copy is tiled with_the_county building inspection 1 8 2-Family,Sq.Ft. � S — 5 LOCALITY , .tlepartmenL Multi-lamily SQ.Ft. � " � — � � NEARES7 - � -Date ' � Residential Swimming Pools CROSS Si. Applicant �� O'rvrvER oR ( � FIRM NAME G�+{J CERTIFICATE OF EXEMPTION PROM WORKERS' � � � Mq�� � � � OuUets Fe l'ght_Sw COMPENSATION INSUFANCE � ADOaESS � _(Thls 9edion need not be compieted tl the work involved by lhe First 20 - . � permit is tor one hundred dollars(3100)or less.) `' ToWI No.� �pdditional � CITY � Tel.No. - I certity that in the pertarmance of the work lor which this permi[ � � PLAN GHECK , APKICANT is iswed;I Shall not employ�any person in any manner so as�o � -� . �become 5ubject to Ihe Workers'Compensata_n Laws: Ligh[ing Fixtures first 20 _ A�DRESS - - ' /�-'� Total No. Additiona� . . . . Dato� -��ApPlic�`"'�—��l— ' --.. - . -- - _ GTY... . _ . Tel.No. NOTICE TO APPLICANT: If. aftzr makino ihis Certilicate of� Fixed Appliances Not Over 1 HP pEaMIT � Exemption,you should become sub�ect to the Workers'Compensation �nga_Hzatar_ 0.1V. _ ���C�T � 'provisions of the Labor Code,you musl forthwith comply with such--- Oven_ �ryer_ W.M._ � - ADDRESS �provisions or�his permit shall be tleemetl rewked. - � Top _ FAU _ W.H._ CITY ' � LICE�JSEO CONTRACTORS�EGLARATION �- "�� ' � �"-� " �� - � TeI.No. Fbotl—�Fan _Otfier_ I hereby affirm that 1 am Gcensed under provisions ol Chapler 9 Disp. —Room Air Contl. _ UCENSE OR , �(CqmmenCing With SeCtiOn 7000�Df Divi5i0n 3 of[he Bu5inB55 Bntl ' � - � �- REG-NUUBER Ciass�y�$ Pfofes5ion5 CodB.8ntl firy fICB056 IS 10 lull�OfCe and Elfeot. ' DISTRICT NO. PflOGES Y } Power Apparatus 8 Large Appliances c� // � �/1 Size 8 Type HP,KW,KVA,or KVAR ; b O License Number_S�n�C O Lia C6ss� ._ Up to 7 IncL� � � � FINAL U -Contractar-�C��/�G�' 9j� _ Over 1 to 10 Incl. DATE (1�/�j.,�(' . . .VAUDA710N � - I LT G ior Over 10 to 50 InG. ..... . . ..- . .. . . . . � FINAL ❑ I am exempl undyr SeC. Over 50 to 100 Inc. gy � �U . . _. .. .. . . . �- - Over 100 ... . _ .. . _ . . . BSP.C.for this reason �� � � � �- N Scrvices,Sw6d.,MCC 8 Panelboards.... . . . . . , _ z ^ �����` � ` ' 0-200 Amp.Under 600 V � � S'cnat��� - ��� 201-1000 Amp.Under 800 V . , _ .__,_, . -❑ �- � �- � �� � � � ... Over 1000 Amp.or Over 600 V Exemption tor Reg.Naint.Elect. _ . _ _ . �15&4A ��-�-�-- � - � SINGLE FAMILY � � ��� Temp.Power Pole 8 Appurlenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � "� � � -�-� ' � -� �� � - - - - u�� • • •G - I herehy aifirm that I am exempt from the Contractor's License Law for lhe following reason(Section 7031.5,Business and Professions _ Addilional Si9n Branch Circuits .I •.�3 b 5 0. . Code): � � - �- - -- . .. � Misa Conduits&Gonductors . . _ _ _. . • • •3 f.5��, I,as owncr of Iho proper�y,will do the work and the structure � is not intended w otfered for sale(Section 7044,Businoss Other�See Comp�e�e Fee Schedule�_ 0 9� 4-8 8 and Protessions Code). � ,. .. _ . . . . . . . ' CONSTRUCTION LENOING AGENCY . . . .... _. . _ . ... _ .. . . . . . I hereby aflirm lhat there is a tOnstruction lentling a9ency IOr�he - perform�nce of lhe work for which this permit is issued(Sec.3097;- pERMIT FEE � (Sub-Totap Civ.G). ^ . . . . . . . _ _ . _ . . .. , .//� PLAN CHECKING FEE Lender's Narrte fV/ '�� �� - � � �� . � - � PERMIT ISSUING FEE O, ..._. . . . ... . _ �Lender's Address � � � � � � � � - I certity thal I have read this application and State lhat the ahove TOTAL FEE information is correct.I agree to comply with all County Ordinances � �� � � � ��� �� and Stale laws regula�fng Electrical wiring,and hereby aulhonze representatives ot this County to enter upon the above-mentioned � - - � - � ��� � �� - . . ..... ._. . property for insp tion purposes. � � � � � " SEE REVEHSE FOR EXPLANATORY LANGUAGE a��' _._ . . . . . . .. . . ._ . .. .. . ... . .. .. .. ol Permittee Oate .. .. . ,--�a �€ � � s � �•c �'r. �� "' b �=�oy /� - y �e � 3:N h '3�1"��a' �m � : - :-� --� - ' .! .: .. ^ :._.!J H a y�` " �C� ��� l�� �y V! .�+,.� . � J ._.. , ' ' "' .. : .. ro � � � � ' - � �./q.0.N C � a C'�.y'� .= /�����.�'� $��'� � � . ... . . 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