Loading...
HomeMy WebLinkAbout1717A (10) - WORKERS'COMPENSATIONDECLARATION 76A6fi3 +oi8� qppLICATION FOR ELECTRICAL PERMIT {� I hereby affirm that I have a certificate of conseM to seli insure. CE-Bo6G or a certificate oi Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY u copy thereof� c.3800.Lab.Q) Poi;�n,o. J�/��li�?omaam/�'�v5�i/�. FOR APPLICANi TO FlLL IN JOB �/' ❑ Certified copy is hereby furnished. /Np. New Residential Bldgs.S PooiS��� � EACH NO. . FEE A�oaESS�� 77' ��j� ��' - � Certitied copy is"filed�with ihe cwnty building inspection 1 8 2-Family,Sq.Ft.�(Z_ `� — S LOCALITY��p � � � �-- � NEAREST D P t fyt: '.� �' '/�/J�,�� y�•-/-,��,� Mulli-f�mily$q.F�. CROSS 5T. �,Td/.... _. - �%'�N�//'�I�.SL.SC_ ReSidentialSwimmingPOois . Date- Applicant , � OwNEROa /��� � . .... ... ' FIRM NAME . . CERTIF�CATE OF EXEMPTION FROM WORKERS' -� Outlets:Rec_L'ght_Sw.— � MA�� ? ir y -�� � COMPENSATION MSURANCE ,� . � . � � , AODRESS d� ^ .(Thk seclba need not be completed M the work invdved by the First 20 permi[Is for one huadred ddlarc(S 100)or less.). Totai No. Addi[ional- '� CITV n_ � � 9�' I.No.�-�Q(f� � �I certify that in the peAormance ol�he vrork for which this�permit . .. , P�nN CnECK - . Af'f'LICANT ' ' is issued,I shall not empioy am/pfr5on in arry manner so as to � become suhjetl to the Workers'Compensation Laws. , L'gMing Fixtures First 20 - ADDRESS- �� �� . . . . � ' Total No. AAditional . . . . . . .... � ' �- CITY � � Tel.No. Date Applicant - Fized Appiiances Not Over 1 HP NOTICE TO APPLICANT: tl,.aiter making this,�Certificate of PERnniT �,. Exemption,you should become sublect to the Workers'Compensation Range_ HBetBf_ D W. _ APPLICANT� (,� �provisions of the Labor Code,}rou must forthwith comply with such Oven_ Dryer_ LV.M._ � ADDRESS- ,O x ��� provisions or this permit shali be deemed rewked.� , _.7op,__ FAU__ W.H._ -nn (y /r� � . .... CITY� � I��'V r�7Od' Tel:N. �IPy .. UCENSED CONTRACTORS DECLARATION - Hood_ Fan _ Other_ I hereby aHirm that I am licensed urMer_provisions of Chapter 9 UCENSE oR (commencing�with Setlion 7000)of Division 3 01 ihe Business antl � �� Disp. — Romn Air Cond. _ REG:rtU�+t6ER - -� - - Gass. .l � Profession9 Code,aM my license is in full force and eflect. power Appantus 8 Larpe Appliances a57PIC7 No. PnOCE55ED BY � .. . . . . ... ' _ _. _ ... . .. � . � C JG Size 8 Type HP,KW,KVA,ar KVAR ` a, o n P $ Lieense Number�`D�3. Lia Class . . . -�UP to�7 Incl. • - . . FINAL� . .. .. . . . -.- Contrector ������f7` bate� -- -- _ . �r 1 to 10 Incl. DATE ����/p� ypLIOATION 0 0 Over 10 to 50 Incl. -- ❑ I am exempi under Sec. �� � � . OtTr 50 to 100 Inc. gy A� ��4,� U __ . ._ .. . _. . . .. . . . .. . ._.. . _ 8.8P.C.for this reason Over 100 �• � Services,Swbd.,MCC&Panelboards �- - � � � � � � ��- - . -. . Z __ _.. ._.. �ate: 0-200 Amp,Under 600 V ^ Signature 201-1000 Amp.Under 600 V - - � � � � � �� �]�,I{� .. . .. _---. ._._....- ----.. -_ -- _ � OvCr 1000 AmD.or Wer 600�V --. . . .. . . ❑ Exemption for Reg.Maint Elect. . .-.... .. . . . . �. e • . e� " ` ---- - �- - SINGLE FAMILY ' ` Temp.Power Poie 8 Appurtenances - HOME OWNER-BUILDER DECLARATION - �'���� �' �- �' �- ��--� � - -�- --- -- -� ��� °9 2'Y.O I hereby affirm that I am exempt from the Contractor's License Law Slgn with One Branch Circuit !or thc Fa"owing reason(SeCion 7031.5,�usinass and fYc`zssions �� AAAitional Si�n Rrarrh firczuts .• : ,C�O n� , , _... Coae1: ... . ... . . . 09.20-80" ❑ I,as owner of the wili do the work and[he structure Misa Conduils 6 Conductors � � � � �-� � � -- --- ... . . .._.. ...._ n�e�Y� Other(See Complete Fee Schedule is not intendetl or olfered for sale(Section 7044,Business )_ . and Prolessions Code�. � "- �- � - � � ' � - - - �- � ----- - ��- - � CONSTRUCTION LEND�NG AGENCY -- --.- � � - ..._ . � _ ... . . ._. .� 1 hereby alfirm that Ihere is a construction lendirg agency for the � performance of lhe work(or which this permit Is issuetl(SeC.3097,__ pERM1T FEE� �� -�� - � (Sub-Total)- �a � . - . _ . ... . .. .. . _.__. Civ.C.l. . .. . . ' ' ' .. . PLAN CHECKING FEE . . . . � .. . ... . . ..._ ..... ..... .. . ...._ Lender's Name � � . '� _„ ,PERMIT ISSUING FEE__.__ ._ � � Lender's Address � � ' I certiFy that I have iead this application and state that the above .__ _TOTAL FEE �Q , , ._ _....._ . . . .._..... . .. .. . .._. . .-'-- . .' --. . ._.._.. _ information is wrred.I ag2e to comply with all County ordinances � , � �� antl State taws regu�ating Eleclrical wiring,ard hereby authorize � repreSentaYrves of this County to enter upon the above-mentioned � - - - � �-�"' � � � "� ��-��� ��- � - - - �� � � � �- - � � -- ----- -- � � prope for inspeet�urpos� ��� ... . . _...SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date �..,,:r. • r.•,'=°' . _...._ , _.__.._.. . ,.. . .... � --- ... I- - - -�� \--- -- •I--� -i-I--I--�I-..i-----I--i —1 . �' �i �' I `' � � i';, I � I i�,�, � �. . :•" I � � I 1� I � •^ � ' � '�r ;�!, i I I If ' / i ,�c -.�I,r ; '<:-, _ ' 1 y` '/ , I - � i �V.. I :! I � �.�. ' '/' i I ' , '` I� '.' ��' i ` .__ 1- - - - - i.' � j Y�r I I' ` I � -i,i i � �� �=` v' -n` � .�o c '� � , i , ' , •' o D � � � '� ,O o { .. ; i . I I ' ��.' � ` '-- ,' ;� N r � 7� � � .G� � v, �' I '; .. • ! � 'c '� ' ;J I n D. 'cmi�� c� �' O D i . � j f ` � �;' � o � � � � '..-�°i I ,'- .'." - �, �' .� r � O p' C O b �. � .. .�� m m � � O �j r`. '. . - . � .p p . , i. - ' I . , . . :- ;.� y . . . + . .��. _ ._ ._...:. ._,___....- - ' " ' .'.'- ' - ' '-- -_ " - . . - `. ' - � _ � I .' ; • � c '1 . ' � I : � _ � : , O ! ' i ��.. i . :f , '+� - i ; -. �I � ,i, m � � . � L•� __'_ _" 1 _ i _ . _ ! . ._ .. .. '_ ' _' !`F� ' .. � y. ' i" _ i i 1 _ _ _ I". n. i � , , . , 1 � . . . '"_"' - . . I � � cn� ; _. - 1 j � ': i • . , , Lrn • � - . � v - ' � � i � . . 1 1 � � � . . � _ yn . '. ; I. I.. '__' ' ' '_' " " . _ .. __ . _ m� ' • 1 -. .., � ', ' e � , . . ' .. ._ .. . � ! ' -- �i.,. i ' - � : � �� ' , � _ . . . . .. _ . . . � _ . . i I i -� _- - . . �' - ' ' ` �. . i � - � 1 � ,_ ' . ' ' - i .. I � _ � I . ' . . ' I [ �'� i � . ` . � , � _ _, _ ' �, • ` � � • � . .. � . .. '- . ' � . � � ' • ; � .�— _..� _-__ _�.__ . '. _._. _. . _ '_ . .._ . . . ._ _... _.. . ._... ........ ..._ ..._ _. ........ ...__.._........ . ._..._._.... .. •.""" ' .. . . � . , - � �. . � . , � i . . .. '' - �� � � ! � - . � 0 �i Q7 /�, !~ ?O � � Q�C y .�1..' Q,.�i � C� G7 O G p��j�� �- �.:� ' , . ! .I- ` � c� � � � 4 F °„' o'o c 'K m` � � m _:�'•o � � � . ,';'I � - _ 3 � sp 3 •i :q.b �o ��' � �O� �.� ` ��o u� � �% �i ✓� . .. .. � � ,X.. i . '�;,. cci�d o:� � � �' � n���. � o,Q ' . .{:. ' i . � '. i , '� n .�I !�,' .0-p' ? C�G A _ Q ' k �'V� fn .� � � _�.. .. , � ' I " O i� �Q 3 � �.�" i ?'-`� ,f', `D R o c c^, �':- m = ;;V � , . . v c �tro � aQ�'� o �� � ogj �� w_'�no 3 p - , � _ .. agc � c� � $ g � �� g � Rmm�$ o � � i - � . ' . . � .. . ' m i� . .���� � �.�.y ° 'n; � � ., n O q � o s .. � �. Z __ � , , - , �; y �� �- o N Q �.�. n y o r-'� a� - m , . I. .. . f� I 6 y �' � ry � � � � ^.�Do�� w- 7S. � N fA ���. Q�.� a � rn< �' �'c' � c m � �- .m _ .. I i :. '• '.: __ - ' ' : j .Q �r. ,� � �� �� a � � 4 P p a � � y.Fi�i"4`� � � Cr . .. o x �. i _ �- � : - - , � .� Q� o � � oa°vcy �$ w � $ � Q . �' O . i. '; ' � i ' ' - ' -� �.'� 3 � � � a `� � c�, � `Dg � � �' �v� �c� u'� �' i! • � � � I �. ,_ � ... ' ti :` c ^ �p-v' O Q- � � p �-�(7��.? �` C o ' . 2 � � � m � Ir! " - - : � :. c-. t;- _� . ' ;,.� .� � y. 4 � � �i�� ` � N� �� S? QF 3 � ` ' ' t I I `" - - r. :. � . . . �„ �„ � `� � �,(� y � �+ � i� 5 S � � , . ,�` fD tr � Q F °� `� o o � ��y� �� Q�. �.w c� D , . .. : . ._ �I ; ,' .✓ ,o.c C. Q v �D � ^ N .,.f a o. ,.'i�l . .. . t, " I �. �- ' _ _ . �'N � � O ?� y I ('�� ` O V ? y n�� G 7 C' (71 j ^-I�I �Gl i � CJ � � C1 K .i' - _ - _ ,"i - - I , i� ie o j R.3 � i � °' w �_� � � � O' , ' - -- - � i . - � 4'�? �� p ��j� _�r.,.a� �� �,� p^. Z� . `�t:, � �.N N � , ; - - . - �o � �" � g " ` tia � p � _ : �,c � S �' o� n ,ca �-`�Ov � �- ' •�. _ ._i ,� � `f�'Q o R. ` a �i'c �r� $ �. o� _�,= I ` . 'J - _ . _ � _ '� - , � �,� n � y � '.�� � � $ � � E �. Q; - ' �-