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Home My WebLink About1392A (7) .. ... _ __.._._ ... ._.__ -__. .. _.. . ..._ __ _ ------. - — _.,---._._.. � -� =�.. _ , .. _._a_.... WORKERS'COMPENSATIONDECLARATION 76A653 10.'81 �pp�ICATlO�I FOR �ELECTRICA�r��P�ERMY7�.�,� � I hereby affirnA that I hove a certificate of cansenY to self CE-8a6G insurc�or a certifimte of Workers'Compensation Insuronce. COUNTY OF LOS ANGELES BUILDING AND SAFETY - � ar a cert�f�ie/d mpy i�he/r(e�of(Sec 3800;Lab.C/'.) Policy No.Pi�OLn'7 Company ��UL�`�� FOR APPLICANT TO FiLL IFi' J06 �7 Q �f l,�,�� (.�.j � Certified mpy is here6y furnished. New Residential 81dgs.8 Pools EACH ND. FEE ADDRE55 L� 1\j j.nj] � ��C.1 � Cerfified copy is filed with the county building inspec- 1&2-Family,Sq.R. g — S LOCALITY �tion depart nf. Multi-family Sq.Ft. — NEAREST CRO55 57. �( Residenfial Swimming Pools �+ f �p Date � `�3 Applicant� �� F�IRM NA�A E L.QL�Wi�l�. Ch�cker F� � CERTIFIGATE OF EXEMpTION'�FR0141 WO ERS' O�tle�s:Rec_Ligh!_Sw._ '�� 2� L �L � � ' COMPENSA710N�INSURANCE � � ADDRESS �jp (This section need not be complefed if fhe work involvod 6y First 20 fhe permit is for one bundred dollars(5700)or less.) Total No. Additional QTV ti��-�� Tel.No. 5C 72 Y P P�N�HE�K A.C.Atl�er-ta�, -�� I certif that in�he erformance of the work for�which ihis AaPLiCANT �� permit is iss�ed,I shall not employ any persan in any manner � so as to become subject to ihe Wo�kers'Compensation Laws. Lighfing Fiztures Firsf 20 A�DRES a C .r M, . . � _. . . Additionol Date Applicanf Fixed App�liances Not Over 1 HP ERMIT f�� Tel.No. ��-7�.l� NOTICE TO APPLICANT: If, ofter moking ihis Certificaie of APPLICAN7 � Yy� Exemp7ion; you should become su6ject to Ihe Workers' Ronge_Heater_D.W._ .'��J I l • Compensation provisions of the Labor Code,you musl forth- Oven _Dryer _W.M.— ADDRESS � wiih mmply with such provisions or this permil shqll be Top _PAU —W.H.— deemed revoked. Hood _Fan _Other_ � CITV Tel.No. LICENSED CONTRACTORS'DECLARATION � LiCENSE OR �p�-- I hereby pffirm ihot I am licensed under provisions of Chapfer 9 �isp. ._Room Air Cond. — REG.4t1MeER Class. �� (mmmencing with Section 7000)of Division 3 of the Business power Apparotus&Lorge Appliances DISTRICT NO. PROCESSED BY � ond Profes;ions Code,and my�icense is in full force and effect. � - . /E A{l f('j � �/� Size 8 Type HP,KW,KVA,or KVAR i fC7 �'-I � License Number `t'`i-iL:?f-i Lic.Class "t'� . � Up to 1 Ind. FINAL ,r._ v -'�� -C�i'{ ., '�� Over 1 fa 10 Ind. DATE �� ,� - r'>• � CoNractor � � Date�� VALIDATION � ❑ � � - Over 10 to 50 Ind. _, e-� FINAL I am exempt under Sec Over 50 to 100 Inc, BY �1��„� w 6.8P.C.for ihis reason Over 100 � M - - � Services,Swbd.,MCC&Panelboards , � Date: 0-200 Amp.Under 600 V Signalure 201-i0D0 Amp.Under 600 V Over 1000 Amp.or Over 600 V � Exemption for Reg.Maint.Elect. I SINGLE FAMILY � Temp.Power Pole&Appurtenances HOME OWNER-BUILDER 6ECLARATION Sign with One Branch Circuit � �- ' :�`7.=.Fi 1 hereby affirm thar I am exempt from the Contractor's License qdditionol Sign 8ronch Circuits Low for Ihe following repson(Section 7031.5, Business and � �, ; a�, Professions Code): " Misc Conduits&Conductors �.�S�.r� ❑ I,os owner of ihe property,will do the work ond the ' ' siructure is not intended or offered for sale(Section Other(See Complete Fee Schedule)_ 7044,Business and Professions Code). / "� - ` ._: ..;�c: � CONSTRUCTION LENDING AGENCY u L�.G C�-'v L'� I hereby affirm thot 7here is a conslruclion lending agency for 7he performance of ihe work for which this permit is issued PERMIT FEE (5u6-To�al} JS fi'�j (Sec.3097,Civ.C.J. - - � � PLAN CHECKING FEE Lender's Nome j � , � , PERMIT iSSt11NG FEE >� Lender's Address �( I certify ihat 1 have read ihis opplicalion ond state thoi the TOTAL FEE above information is correci.I ogree to comply with oll County ordinances and State laws regulaiinq Elecirical wiring, ond hereby authorize representaiives of this County to enter upon � � .the a6ova-ment�oned property for�nspe<tlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE @�'��.�'�rtr�. �"_�L��e Signature of P mittee Date ' APPROVALS pATE � �E� � � OWNER-BUILDER DECLRRATION 5!GNATURE TEMP.POWER POLE � i here6y affirm that I am exempt frem the Contractor'; Li<ense Law tor fha 4ollowing reaeon (Section 703?.5, UNDERSLAB WCRK � I 9us/ness andPro�ess(ons Ceda):Any city or counfy v+hich , ROUGH CONDUIT ^� requfres o permif fo tnnstrucf,offer,improve,demoli<_h, . . � . __.._ - or repaG any s!rucfu!-e,pr(or to its issuonce, a7so re- . WIRING qulras fhe apptimnt for such permit so flle a signed sime- . � � ment that hs Is I!certsed pursuant to ffie provfs;ons o5�he , FIMUP.ES Con;racfor's License[aw(C6ap�er 9(cammenciny wilh - � POWER AUTHORIZED Section 70Q0)of Divislon 3 ot the Business and Profes- . sions Code)or thaf Fe is exempf the,efrorc,ard the bosi= ' " � UTILITY CO.NOTIFIED I for Phe afleged exemp4ion. Any violation of Section � FINAL n 7031.5 by eny opplicant for a permi4 sub(ects the oppL- Gnfas ort �van� cunt io a tivi(penoHy cf not more fhan frve hundrad - � � ..„ .,,_,..... ... _. ...__.. .. . . ,.. . _: __,_.._...:.,.......-. . ,., - .�. '�� - NO7E5 � - dallars(y"SOQ}.: � � ❑I,as owner of tha property will do fhe work,and � ' the struciure is naf intended or offered for sale. � � � � "� '�""i��"�`�"�"-""'""�"'�"""""""'""""'"°""�"" �`"""��"'�9t"�'�'""uJ91'�""'(Sec.7044,BusinessandProfessionsCode: 7heConirac- � fer's Licettse Law da2s nor apply!o or.owner of property ' � ` -��""'��"��`"""��"""""�""""""""`""""9"""'"""'""' � . � �"'""`"""°"wbo builds or improves therean, cnd wRo does svtF _ work Mimse(f providr.d that such improvements ore nct . ...,.___.....,....,.„..,_...„.�.,,,.„_.,......._>___.,_.,,,_,,..,.,_..,.:,,,;;�:..,;,,�,,.,...r.a„_,;;,,.,,;,,Q..,�;,s,;,,,�uz�.,tt,«.�sy.-�.n.s.;e.�:.,yw�,�a�n'f�ended or oifered for safe.1f,hawever,the buildin�or � � - � . improvemenf 7s sold wiihln one year of completfor.,Ihe . __ _... ._,,.-..__. .........,„....W...__..-......�.�r._.....,,. - . , ....._...,...._,__...e..--.,....}.a_;.�.d::m..:......,:::...�:,.:w..sw..:..:.,.:�rs.,,.�,c....:x�:�ow"t��F=6uifder wil!have fhe burden of proving ihot he o'id - � - - - - noY�bufld ar Impreve for tbe purpose of safe.) -:._....._._..�..__...�_. ......_.......«.__................._...._....,....._.......�..,...,.-»•,....:,::,�w.+e:..m..y.w.��:,�..__...:w:;.�._...,�:.xv.u.�.�.......s:.:,:-,.:.,,�.a.,�..:.�,x'.,�-,�,�=-% _ _ . . . . ro:sx.:.z.g-:d.:.�::�.._.....;._a.:.,L.�..._.., � �- � � ' I am exempt under Sec ' _ . . „ _..,......._...,,.. . , ........... .:..... .... ,-, �..,._..,. ,..,.,.�.x�. � . . .,., . ._.. .�.s��.:•-.,:rrka�:��..x-a�.,zr.�._.....,..eas�a� - w,..ei...g-.:x �ma+,�xw.w.. ,.,....,. ..,.. . . ... ._ . ..___.. � � � , . 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