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HomeMy WebLinkAbout1711A WORKERS'COMPENSATIONDECLARATION 78A883 +o�$+ APPLICATION FOR ELECTRICAL PERMIT � I here6y aAirm that I have a certificale of eonsent to seN insure, Ce-sosG or a certificate of Workers'Compensatron Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy ihereof 1 c.3800.Lab.Q) - Poucy No. compa�y�NO!/STlZ/i�/ND. FOR aaaucawr m Fi�i u+ . .ros ,/ ! ❑. Certified copy Is hereby fmnished.- . ,.. New Residentiai Bldgs.8 Pools EACH NO. FEE ADDaESS�7'y9yC � . .. � � 1 8 2-FamiN.Sq.FL �3� S — 5 LOCALRY yC� �7- T�' � ,�Certified copy is�filetl vnth the�cwnty building inspection _ � � � NEAREST art t. Mo!1i-family SQ.Ft. CROSS ST.� ����✓�,(Q ReS�dBnti81 SWirtlming P0013 .. . ONRJEH OR � /� ,Date� APP�iCaN .- . . . ' . .. • ��. FlRM NAME � (�� � CERTIFlCATE OF EXEMPTION FAOM WORKEAS'- - � � - � - MAi� Outlets:Rec—L'ght_Sw._ ` '� S����w �v � � ...,COMPENSATION INSURANCE - ��� � �, . � � - � ADDRESS-� (This seetbn naed not 6e eompieted if Ihe work(nvolved by the F�rs�20 • CIT �y7 p 7e.No. permit Is lor aro hundred dollars(5100)or leas.), � .. Totai No. Additionai" � - �j�i(' /�(r �-���/ �' "� PLAN CHECK ' �C2f11fy(h0�ifl�IIQ�7Qf�OfR12tICQ Of fhE WJf1(fOf WhICh ih18'p2fflli� '- , APPLICANT. ��� .is issued,I shail not employ arry person�.in arry manner so.as to � "-�� ` ,._� become subject to the Workers'Compensation Lavrs.,... , L'ghting Fixtures Firet 20 � �� ��--����� ADDRESS - � � -- - - - -- � � ' � � � � Total No. Additional.___ CITY � . . Tel.No. . Date ' - �a�a^� � ' ' ' �� � Fxed Appliances Not Over 1 HP PEfiM1T ��'�. /' NOTICE T0� APPLICANT: If, after. making'this.Certificate of qprLtCpNi � �[�..�� «Z�jfJ�. Exemption,you sFauld become subjec[to the Workers'Compensal'ron - � -�-��"9�—.Heater_D.W. ___� . __ provisions of the Labor Code,you must lorlhwith comply with such Oven_ Dryer_ W.M._ ADDRESS .� X ���� �provisbns or this permit shall be deemed revoked. . :� ,� . . ..Top--—FAU-_ 1V.H._��� -7 �y /[�- -". _.. . . ... .. . - �qTY J�� J�/!�b . . .Tel.No.��67�I LICENSED CAtdTRACTORS DECLARATION.. Hood—Fan _Other_ •I hereby aAirm that t am licensetl under provisions ot Chapter 9 . -� Disp. —Ftocm Air Cond. �-_ --�� -� -�- -- - .. . uCENSflOa , ,4��O�_7, , , _._C� (commencirp with Section 7000)ol Division 3 oF the Business and REG.NUMBER (/v OJ� ��� �� P1'Of055i0f13 GOd2,811d Rry IiCEnSe is in fUll IOrC2 d�d BNCCt. .poW2I App8f21u4 8 L2�98 AppliaflCeS�--� � DISTR�CT NO. PF70CESSED BY '� __. ..-.._ . .._.. .. .. { . .. 1,. 1 • /�p Size 8 Type HP,KW,KVA,or KVAR l� �„O�\O f�e � License Number Z/�� Lic.Class��V � � � � - �Up to 1 IncL � V FINAL .. .---�EZ.�L�/�. ,.,..L� . _ Over 1.to 10 Incl.._.. DATE '2-��/� � Contractor Date� �--� -- --. .VALIDATION . ._. Ove�10 to 50 Incl. FlNAL . . . .. . V .❑�1 am ezempt under Sec. �-�� '- � � �"� • � - �� Over 50 to t001nc.�-�. . % ^ .., . BY ._... , _ _... . . . __ _'.' _ Ltl o�r,00 � �'�� o- 8.8P.C.for this reason cn Services.�wbd..MCC 8 Panelbbards-._ . . ._. .. __ . . , .. ._. _ . ._ .--- - �� ']�.�I 1� Z ----.. _... . ... . ....._. . Oatci. .. .. 0-200 Amp.Under 600 V Signatura � �-201-1000 Amp.Urid=r 600 V� � � ` ��� � ���' � �� � � - --- .. .. .. .... . . ... . . __.. ... _ .. . . .. .. • • • Over 7000 Amp.or Over 600 V � #• •G ❑ Ezemption for Reg.Maint.Elect. ' ��'�� � � � �-�-� _ _. ---� ; 1 0 3 8 6 SINGLE�FAMILY���� �� �� � .Temp.Power Pole 8 Appurtenances . . . . .......... . .. .. . .. . HOME OWNER-BUILDER�ECLARATION Sign with One 6ranch Circuit • f: ` I hereby aflirm that I am exempt 1�om the Contractors License Law ' � G"�"U=� f^r!!+.�re!��ii�rezsen(Sec!ion 7031.5,Bu�in^ss and Profcsoicns -� Additbnal Sqn Branch Circuits. - .- -- - - .... . . . ... ... .. . . . '- ---.- .... Codel: ��.��-t38 . -.- ..Misd Conduits 8 Corductors" ' . . .. - . '. -.-. _ ..... ._. . . __._.. . -_ . ❑ �,as owner of the property,vrill do the work an0 the Siructuie � is not intended or offered for sale(Section 7044,Business _. Other(See Comp�ete Fee Schedule)_ ► ' � . _ .'_' _ ___. ___.. .... .. ..._' and Professions Code�. - CONSTRUCTION LENOING AGENCY - � �- - "��-�"-'- �"� - � � �"� � � " -- I hereby affirm that there is a construction lending a57ency for the performanca of the work for which this permit is issued(Sec.3097, - � �pERMR FEE� ��" � "" """���'-�-(Su6-Totaq � � 3 G � "� - � - - �� -�� -� -��- � - �� Civ.C.). � . - PLAN CHECKING FEE ---- �- � � --� � - �� � � � � Lenders Name �-- -PERMIT ISSUING F[E� � --�-�•� � � - - � �-�-�0 _ _. __.-.. . . - � .. . ._ _ ._.. .. .. .. Lenders Address � q I cartify Ihat I have read this application and state that the above�- -TOTAI FEE ........... ... .. . . .. .. _.. _. ..��p�j .. .. � . . information is correct.I agree to comply with alt County ordinances �and State laws regulating Electrical wiriry,and here6y authorize .. . ._:. ._. ... _ . . ... _ . _ _ . _ . ... . . . . . __ __._. .. . . . . ___ . .. _.... . ... �fepre5entatives of Ihis County to enter upon the above-mentioned � prop ry for inspection purposes. � - C%� `I �._ � �G�� -�----- ��-�-SEE REVERSE FOR EXPLANATORY LANGUAGE- �--�� � -� - . .. .._. ._ . . ...... ..._._ .. .... �'1 Y�_ ' Signature of Permittea Date ' � , . .. . ... .. _.;r_�.'� l,�^' , ' _' .,�• ,`_ _ri ; i ..���._.i...�,'•i- -i--i � i,�^j - , � � � i', i I •t. I � � = �' .� � ; I �,; ! � ; �, i � � � � �_ i�- ;i � � ; � �;� �:� ' j ' - ` ( I � ' I ° I ` � I�_ ' �i 1 .. . i �' ;; -- I ;I �� , , j�� i,l v, i _ f i ;i" .. � I � j!.. .' �,.'. �-l�i;_ ,�� I ' i-- -i ---- --- ='j' . 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