HomeMy WebLinkAbout0954A (5) WORKERS'COMPENSATION DECLARATION Z°�°°roo°�`�3ie� APPLICATION FOR ELECTRICAL PERMIT Q
I hereby a(firm thot I hove a ceni{��o�e of consenl to seH �A�
insure,or a certifica�e of Workers'Compensation Insvrance, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
or a cert7fied copy thereof�Sec.3900,Lab.C.)
0 �.�.
Po��ty N���Ompony �(iu FOR APPLICANT TO Plll IN !OB �
�Cerliiied copy is hereby fumished. � New Residenrial Bldgs.8 Pools EACH NO. pee .4DORE55
Certified co is filed wi�h the couN buildin ins ec- I 1 8 2-Famil 5 FL $ — $ LOCALITY
PY Y 9 P ' Y Q NEAREST � \�
�tian deparlm{e�npL � Multi-family Sq.FL �ROSS ST.
Do�e��LLApplicam�����- Residential Swimming Pools pwNER OR � �
iIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' �� putlett:Rec_ligM z Sw._ ��� � �
COMPENSAT�ON INSURANCE '�., � 'fs A�DaE55
First 20 i
(Thts�ectlon n�ed not b�compialed if tha wor�tevolved b� ��. Totol No. � Additional UTY Tel.N
}b�p�rmH is for on�huedr�d dollor�(5100)or I�tt,) . PIAN CHECK
I certify fhot in 1he performonce of Ihe work ior whith ihi5 , APPIICANT � �
permil is issued,I sholl not employ ony person in ony manner � '
so os to become subjec�to the Workers'Compensa�ion Lows. � L'9hting FiKmres Fi�s�20 ADDRE55
� . - Additionol
� 7otal No, CITY Tel.No.
pore Applimnt Fixed Appliances Not Over 1 HP pERMIT
NOTICE TO APPLICANT: I�, ofter moking this Certi(imte of qpPUCATION �� J
Ezemption, you should become subjed lo'1he Workers' Range_ Heater—D.W. _
Compensalion provisions of Ihe labor Code,you must forth• � Oven —Dryer —W.M.._ ADDRESS � V L[�
with comply with such provisions or this permit sholl be , 7op —FAU —W.H.—
deemed revoked. Hood —Fan —Other— CITY�. � �Q fjel.No. �^�r 1 .
� LICENSED CONTRACTORS DECLARATION uCENSE OR ,
DiSp. —Room Air Cond. — L(Q CIosS!►
I hereby affirm�hat I am licensed under provisions of Chopter 9 - REG.nIUMBER .
(commenc��g wiih Seclion 7000)of Division 3 of tha Business power Apparafus 8 large Applionces DISTRICT NO. PROCESSED�Y Q
and ProFessions Code,and my license is in full force ond effec�.
/� ��(�.� $ize 8 Type HP,KW,KVA,or KVAR 2r- O
License Nomber��y���� Lic.ClassS�� � Up to 1 Ind. FINAL
�'T^�I�� y.J�cj �DO Over 1 fo 10 Ind. DATE �. . VAIIDATION. . �
Contracto�� � Date �d Over 10 m 50 IncL . O �
aFINAL
I am exempt�nder Sec. Over 50 to 100 Inc. BY W
8.8P.C.ior ihis reason Over 100 , n-
� Services,Sw6d.,MGC 8 Panel6oards � � - - �
Date: �' rj z
0-200 Amp.Under 600 V
Signoiure ' 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 5W V �
Exemption for Reg.Ma�ni.Elect.
SINGLE FAMRY �-�c�'4�
Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION . � �' • • • e? �
I hereby affirm Ihot 1 am exempt from the Conhodoi s License Sign with One Branch Circuit << "
Low for thr.fallowin nenn f$nc�inn 7p31.5, Posin?ss^.^.d Addi�ionol Siqn Bronth Cireuils _ .
�rr � • •���,i��) -
Professions Code): �
❑I,as owner of the property,will do fhe work and the Misc.Conduiis 8 Condudors ' °,'�7•n�T
srroctore is not in�ended or oifered for sale Section 7044, . Other�See Complete Fee Schedule� , .
Business ond Professions Code). ( � Q�,��—R�
CONSTRUCTION IENDING AGENCY
I hereby affirm ihot there is a conslroclion lending agency for . � _
the performance of Ihe work for whith fhis permit is issued �. PERMIT FEE (Sub-Total) ,�
(Sec.3097,Civ.C.). . -
� PLAN CHECKING FEE
Lender's Name � -
PERMIT ISSUING FEE O
lender's Address TpTAI iEE Z�� �
I tertify tha�I have read�his opplico�ion and sta�e ihat�he ,
above informo�ion is mrrect.I agree to mmply with all Coun�y �
ordinances and S�a�e laws reguloting Elecfrital wiring,ond ' .
hereby thorize representatives oi this Co�nfy to enter�pan
the o e-meM'/ned property(or inspection purposes. � ' _ SEE REVERSE FOR EXPLANATORY LANGUAGE
7�� . . Os
Signaro e of Permi e Date �
I
Z T -Ci o T � p z 'm .
o Z � a � c o �
m � r m � 2 L) m ;o
N � .� m G� _ lAt7 '� V
f) O .n
O � N � � m � .
Z � � p v D
O � .
�, rn "� x m c�n
m p
� v
�
q
1
. O
O
-D-1
. 4+"� m
. o
a
�.
cnz
��
zm
a�
- CO
9�
my
m Q �. =^a a � r—
O d � _. mo ��D �4m m `�' m24.� � c° ot� aa �
' _ L � � ' .' Cl� m ? �O j n N ? � ��y N � � � N fp �
� <D � .G < �c a^ V�' C .'U O m O �^ O � o � Q . .
m o a :n� 3� mo� ' u, o � �o ���c .
~ � � �? So �va� i� �.� ^ � may'c�iti.� = O
� 9 �' ? b A n a�m ❑ a v`G �pV O G G' a' tn O� 'L
' Q Q C � O $ tn N p� � .S^ � � Z
. . ? C � O _fD � in j a N G ?.� N � n � S �T
!° 0 3 � , in � �N "� �' m C' � o�c� j � 3�c� v 7J
� a �,o c' a m w a? �'u�,� _� p Q o D j o` G7
. • u, � . oc o �aam - a ¢ N � o � o c
� p cs < - p t' n � p g un, � 4'r�. � `� � p' f-
� n '.. mm � � a�c � n ' � tn� o�i �ac' n.�3 p
. : � o c� � o n� � m w� � �a-c� m m
. '� �.m , y � i,�„ � a' o o 'O m �, "' � ° c � 37
� en o ,,, v m � o �� o � m
. � ..'b a@ 2 n j j O v t' p o3i q°' q n c j� RI
" .. __gO � aFm �, mo '� Vaq� n2'?Ky � C�
N ��+ 000 �a� � � � ,�,,?a.�o � � o �.h
' Oeno �o6 0� �� o � �c ^ moi�� y'
In � ? , �..,
� n' m �� ?ao �'cy_ ❑ �� o ' � pQ' ._O
�
�-�° e5aa< �' m � oUOQi� " c ��-�n Z
, `� ? p p � p � 3 b.j�� � �'y"y �7
' - ' O m 5 .-�. O O^ fp � j'� ^ p� � 4�
j.0 Gyi m C ¢� .� � �y , � 3 n$ j n .
0o a o
� - . d � j y � 4i 5{U O 1c O�.O =' � �
. . _ 6�i O ti� 0 N G 7 Ib Q(�i��O T' O m 3'vyi N