Loading...
HomeMy WebLinkAbout1369A (7) � ' WORKERS'COMPENSATIONDECLARATION 76A863 ��/e� APPLICATION FOR ELECTRICAL PERMIT � �ne26y alfirm[hzt I have a cer6fiCate o1 consent to self insure, cE-8o6G a a certificate oF 6"Porkers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy ihereof(Sec.3800.Lzb.C.) . POIICy N0. ' � CAfnpany FOR APPLICANT TO FlL�IN � �-� - � � � � JOB � / ❑ Certified copy is heieby furnished. � EACH NO. FEE AODRESS . l ... . . New Residential Bldgs.8 Pods _� -Certified copy is fiied with Ihe�counry building inspecNon 7 d 2-Family,Sq.Ft. S — 3 LOCALITY -�[ ? � • depariment. . . . Multi-family Sq.Ft. — NEAREsr Residential Swimmi PoolS CROSS 57. - Ddie App!ican} '- � � OWNER OR, . CERTIFICATE OF EXEMPTION FROM WORKERS'.. � Jq � -`- - � ' � - �AM NAME 3 r � y COMPENSATION INSURANCE . , Oullets:Rec�Liqht 11 Sw. � s AODf7E55 �S (This sectton neetl not 6e eompleted It�the work Invol�ed by the M First 20 Tctal No.�5,� Additional CITY yi Tel.No. permlt Is lor one hundred dollars(5700)or less.) � q3 I certify that in the performance of the work for which this permit P�N C E iS iSSufd,I Shall not em lo en ny " ' P.PPLICANT �p y Y Person In a manner so as to � � � qdditbn � ADORESS� . _. . .. .become sub'ect lo the Workers'C nsation aw C Mi Fixtures First 20 Total No. al Dzte ^ Applicznt CITY� -������- � Tel.No. NOTICE TD APPLICANT.,If,.after makmg thi CerhfiCate of Fixed Appiiances No Over 1 HP rERMIT -Exemption,you should become subject to the Worke s'Compensatbn Rarge_ Heater_ D W. _ . APFitCANT _ � provisions of the Labor Code,you must forthwith comply wilh such � Oven_Dryer�_ W.M.-_ � - - � ADOPESS� � _� � � provisions or this permit shail he deemed ievoked. , Top..— FAU _ W.H._ � .LICENSED CONTFtACTORS DECLARATION Hood—Fan - � � �-��, -' CITY � V --Tel.N. I here affirm ihat I am licensed under --Other_ by p�wisions Of Ch�ptEt 9 . Dis Room Alf COfltl. _ LICENSE OH (commencing with Section 7000)of Division 3 of the Business antl - p'�— , REG.NUMeea �/ - - . -pass.Gy Professions Code,2nd my license is in full force and effect. D�STA�CT NO. PROGESSED BY - Power APParatus 8 Large APPliances._'_...""'..... . � . License Num6er �`O'� . Size&Type HP,KW,KVA,or KVAR �v �� � Lia Class� - - �-'Up to 7 Incl.-� - � �� FINAL- - �� - �� � ^ Over 1 to 10 Incl. — �Contractor Date��� � - . . , OATE �r`(�� � VALIDATON Q �{t I-}I5! LE�T C,Cp, Over 10 to 50 Incl. FINAL r V ❑ I�rt�exerFpt'Gnder Sec. Over 50 to 1001nc. . . . . . _ . .. BY . .. W F3.&P.C.for this reason ' Over 100 � - � �- - N - ServiCes,Swbd.,MCC 8 Panelboards � O� ����- . . ._ . . . . Z � � -Date: 0-200 Amp.Under 600 V f . Signature 201'-1000 Amp.Under 600 V- -�� �-� - � � -- -- ' . _ _ " � --- � � - �- -- Over 1000 Amp.ar r 600 V Ezemptbn for Fe9.Maint Elect .. . . . . . A ... .. .. .... . _ . .__. ... . . . . � I � � - �-S NGLE FAR ILY�� � -' Temp.Power Pole 6 Appu enances �� j�9 f'� � HOME OWNER-BUIL�EFi DECLARATION Sign with One E3ranch Circuit ��� - �-��� - � �' I hereby ztfirm tha[I am ezempt from the Contractor's License law #� � � � �2 ��.rnA��n��y�.,,..o���,.�ce�����7n3��,a��,.e«�..,�o...�.,..�:...,.. Additional Sian Branch Circuits � codel: - -_ ----.. ___ .._....,....... - - �• �7 2 7 5 ❑ I,as owner M the properry,will do the vrork and the structure Misc:Conduits&Conductors � - - � - . . . . . . . is not intended or cifered for sole(Seclian 7044,Busine55 Other�See Complete Fee Schedule)_ • • •7 2,%J c=i and wofessions Code). _ _ ► 0 9.�f)—8�3 CONSTRUCTION LENDING AGENCV . .. . . I hereby affirm that there is a construction lending agency for the perlormance of lhe work lor which this permit is issued(Sec.3097, . pERMiT FEE�- - . (Sub-Total) Z -. Civ.C.1. � � . . ._.. . . . .. . . PLAN CHECKING FEE......� � LeMer's Name � � �- - ��� -- -- � . PERMIT ISSUtNG FEE � � . . .. _ .. . .. . _. _. _ . __.. . . . . . .. . Lenders Address n - I certity thal I have read this application and state that ihe above TOTAL FEE d 73� information is carett.I a9ree to comply with all County ordinances - �- � �� ' � - � -- -- � ���� and State laa5 regutatirg Electrical wiring,and here6y authorize � � � ' representatives oi ns County to en!er upon the above-mentioned � - �- � � � . .. .. . . perty for I pec� n pur ses. . SEE REVERSE FOR EXPLANATORY LANGUAGE �_ , .y ature of Permitt e Date \ _ � � . .. .. �L.'_G•�� .. .. f�_�� ,-- - � -, - --�— , i ji;�l ;, �i . ` i ; I '. ;` � � . i �,. ; l•. ; i : , � i � � � i � '� �'.. � � .. - I j ` i i � i � � `,� ti. i i i, �, �. ; ; , ' _ � � ;- ; I i � ; ; � ; �: _ _- i _; y:- ; I �._... r�. t: 1 `�' � • ; ;� ; ' i i - I ,; � � _- � ( � Y ..� �i _ i ' _. i'• Y� � j' _ •' � L ` . -- - -4 ' '' ; `��� ; ; , ;,. ';� �- I � � I � � � ; �- � t- - . , �' ��` � T 'OI T� `, '� C '-1• 1 _ w f_ i j 4 I : y n C p x JJ p o � ' _ I ' s) . i. •' m r m C i Z L7 f� �v ` 1 „1.. � � � 1 ��� N � � 37. 37� � 2 � '� �y � �- , ; 1 , ��` i � I O �� 'N) , -� � O ap ( L ' 1 � i. f � •' ^� O � .� p .� 'j + ' ' �• i ; � j m m-- � m �' � . i I ' � ' - `� � O - ' • '-_- ' .... '._ . ....- �- -•_ -, _�` 1 .. �_ '� -� - �' .. ' fD - ' I - - __ �I r':. . . . .. ,.- -.. � �� I , � � i ' ' �.� � i ' � • , _' , _ _ __ _ -. _�_ __ _ ._.._ ' . - , ± . ` i i ,`" � C :..:• , ' L.r ! - , ^j i ; i r� , � i,, , � D , �. �.� I ' �� �t � � m � :� - � : ' � ! '�, i � � i ., . ` � �� i �1 ; - � �- -� �� ^I-- - i ' - .. --- -'- ------ ."r i -- ..' - ;' 1 r -- i � � � I � , I i� � J -. ! �_ . : . '.. ..] . ._. -� - . - - ,- -' - " --- -- - -. .. - --- - -- -' - � ; :,_, � i � , I • �� 1 �, � ! I ! � . ' ' �v i�. 1 I 1 ' ___ I_._ _ - __ _ _ I. __ 1 C� ._ ..� ' -- ; � m� s . 1 ; • . ; - � . , , _ ; � ; _ _. . _ _: ; _, . : � : • � � ^ . ` , i .; � _ ' ,; . �: : � �, . � ` : � . = " —,_ � ; .. � E � � .- ! � ' , �' i -- _,~ :l� :.- ` , 1 i _ _ _ , ' ' - �- . ' , . . :. - ; . , . , _. . , . , .-- . ': ` ; . : .. �� ;.- ;' ' _ . . . , . , _ , ; �._ : , , � ' O p � I i a � agQ Cy�', �, FLc�tno U g g � �' - . _ ` ` � F'.. � r o �, _ � ��_.., � � � `� y _ � dz � � � ...'� . . . .. . . . 7 (D: . � �� '4� � y � � �.n o '� �. p O� in O �p � . � ` � � . . � (� � � t f� .�.� Q C; m�t � n�••��-�~ � � 7. �D -�i. G�j tn' O Q � • ; c.� � Q �_�-' ',' � C� � ' °� S i� U i.N.�--� x Q �' � y ��� Y� 3 �' ! ' '� . � : , , - o rD a �'�c R �c � 'b�:�.� U'� �.�o �i 3�.y n� 3 � � ^ " � 0 3 � � , . I :`", � N '� Q g � � � Qi �� � � Q � + � o _ �c F .. -: : : _. , ; , . � : . _ _ � _ _. � � � � g, �; �' A �o.� ` � °: m ... . � . �o � -„�o �n a � �'� � � �n .. , - , .. ' r� ,u� ' � g..Qv, a � `�2 �.� �.tx.�`-�.� �.'$ g`'� � 3`. � � . �- .. . .. .- . _ • � .r-: .Q � �� F � QQ�� Qo� p��.� cu � yC� rwX . 0 - . ` ' • - - , �. ,� � � � � o'o �D � � �a " � � � � R � � 0 . . - . . . � - � . . � � � � Q � � v o g � O < � � o � y a R7 ' . � � ,-g.�.�. ^ � a � � Q � _ � . ' _. , - � � � n� v� =, � n� �� 9 � t. - - m � _ , ' � � � a � .y v, ° ` v3� �,� ��a Q � � � n - �.. ' . � � � . ; .. �-- A fn 4 ? R n fi._ �n�.h \ y n >, V� . -- i. o �� aF ° 8. ,:o:o �.��`�,� �� � Wg � � . _ ; -• �4o Qa �,.� � . ` , � � : _ � � �s` ---" , -r �' �3 �� � � .n � a m.t; � U �'� `� �'c,. � ,. _ r .. `a >. �,-�' � � �_�' �.W �,, a �t� m c � C7 • . l! . � . - - . ,- . - . -• - . , 'o � Q � F,,� x = cn y. � � � ca5 � y �j, o_ z' , _ � Q � � o ?.'� m � �.. , �m �' g � �� p. .�� Q.��o � � a,�, � .. kc� � �.. � � �' O:e ^� �- i - �..i . . _. .. ... . . '"" ' . " ._. _! . ... .. � i.� Q a N C `C� W� � � C.� ���'� . . . a \�