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HomeMy WebLinkAbout1088A WORKERS'COMPENSA710N�ECLARATION 76A663 +a�e� AppLICATION FOR ELECTRICAL PERMIT � � � I here6y eflir¢i that 1 have a certificate of consent to sell insure, cE-eoec or e cer�i�icate ot Workers'Compensation�nsurance,or a certi��ed COUNTY OF LOS ANGELES ' BUILDING AND SAFETY � copy,thereof Isec.380�Qj� CJ (�.,,��,. � : Policy Na.. I T�� �...�S�C-�•-� . FOR APPLICAHT TO FlLL IN � � . .. �... DDFESS . ..�. v... . / 4-9 6�. Compeny �� / _ . ❑. Certified copy(s hereby furnished.. .. . ;�, New Residential Bltlgs.&Pools ' � �CH�� NO. -FEE� �v / �`��S ,I�� � :� �Certilied copy is filetl'with ihe"county builtlirg Inspection LACALRY i� / � 1&2-Famlly,5q.FL $ — $ u��i aid .t � ���daper nG � '� � -��,� ,�� Mulh-family Sq.FL _ ._ ROSS SL �� - � .Dat¢�?PPliea �/ Residential Swimming Pools � : OwNER Oq -. / . .. . FIRM NAME/� j � �'G/.� �N . . .. � . . .. '. . . <��� CERTIFICATE OF EXEMPTION FROM KERS �" �- '�r ��r- �� � � � '��•.�. �� .� .COMPEMSATION INSURANCE � � � Outlets:Rec7�Ligh[G�2_Sw;-�.� _ _. _ '�. O q�p�pqESS .�G�.Iq e� �(TAIs saetWn need not be completed M tha work Imolvad by the r '� First 20, CITY.- �- � �:.permR la fo�one huMrod dollan(S700)a bns.) ;�.;. . Total Nov�] pddilionai .. . 1 . _ ...._ . Tei.No. PLAN CHEGK' �+ t . �.I C6ftily.that Irl(hB pBftOlmanCe of the Work�or WhiCh this permit "�- `�--"- ' pppV�qNT J�1/il�f �/1/4 r+w�(,��� � �.is beued,I�shall ral empby eny person in any menner so as ro ' , become subject to the Workers'_Compensatan Laws. � ,. Li9htin9 Fistures First 20�� ' - �-�t-� ADDRESS��� ,�4�y� L�a�v �.�L/� � .� �� � . � ' Additional To�ai No.�>� crrv .,�, c �:.✓ � Tel.No.]�9�u17 Date � � Applicant �' � � � � Fized Apptiances Not Over 1 HP pEqMi :NOTICE'TO,APPLJCANT: fl, after.making���.thie�CerMicate of APPUCnNT�.2 ��3 ^��i;,.�� �� ,E�mptbn,you ahouN 6ecome wbject to the Nbrkers Compensation - . �^9�—.Heater D.W. _. __ . . ., _ �,provisiona of the Lahow Code,you must for[hwith comply wilh such Oven— Dryer_ W.M.^ ADDRESS�3 J . /�,�e�7 � , . ..provisions o�this Permit shall 6e deemed ravoked. . . __. ._. Tov..— FAU L W.H.._� . .. - : r � .�LICENSED CpNTR4CTOAS DECLARATION Hood_ Fan _ Other_ � �CITY�•u w7���,� � �� Tei.No.��P�/�P'� I hereby aHirm that I em licensed under prwisions of Chapter 9 .-.. . . . ... uCENSEOR �(COtfIrtlBnC�fq WNh SBCfi0f1 7000)01�ivi9i0n 3 01 ihe BuSine53 and ' DiSp. —�ROOm Alf Cond. _ REG NUMBER�;sl � �� �-aasb�� � Prolessions Code,erxl my license is in full force and effect. . � . Power ADPeratus 8 Large Appliances ._ . oiSTRiCT NO. PROCE EO eY _ , . . l p �,.s� � � I� �3� � Size&Typa HP,KW,KVA,or KVAR U a r License Numbe f �// �� Lic.Class� .... .....UP to 1 InCL . ... . . .. . .. FlNAL � ��11 . . .. �f/d.���/J./7/'"+'�'bete �� aa3/Q 7 .. ' , Over 1.to 101nc1. PATE ;t. I �� . . .. _VALIDATION .. � Contract Over 10 to 50 Incf. b FlNAL V � ..Q.._I am exempt under Sec. � ' � �- Over 50 to 100 Inc,..- gy . . .. . _. _ _ ._.- W ' 6.8P.C.lor ihis reason Ove�100 - � . . - . . . _. . _.-._.._.. Services,Swbd.,MCC 8 Panelboard . .. .-... .;. . .; ... .. . . - . .._.___ _ Z � -���� Datei - ; �0-200 Amp.Under 600 V � ► �� . . .. .... . .. .. , .:_.._ . . . . . . Signature � �201-7000 Amp.Under-600 V�� . , �� - - � " - - �--� .. __ . _ .'__ . _.. . � ; ' ' ❑ � _ . Over 1000 Amp.or Over 600 V . ExemPtion tor Re9.Maint Elect. . . . . ` ..' ..... .�.._. .' -'.. . .. ..�.�. . .. -.. , ... ._.._. ._._ . . . � SINGLE FAMILV� � - . _. _Temp.Power Pole&Appurtenances . � ' HOME OWNER-BUILDER DECLARATION � . Sign with One Branch Circuit . I hereby aflirm that 1 am exempt from the Controctor's License Law qddilional Sgn Branch Circuits� - for the following reason(Section 703L5,Business and Professions � � -" "- �" � � -- '� � �� - �� --� --�-�" -� - � �- � � CodeY . � . . � . . � � � Misd Conduits&Conduc[ors �-� ���� --' � - � �� �- -�,- `�"-"�" � ' �- � --� - I,as owner ot the pmperty,will do ihe work antl the structure is not intended or oHered fw sale(Section 7044,Business ... Other(See Complete Fee Schedule)_ �� and Professions CodeJ. ' � :1 Q88A CONSTRUCTION LENDING AGENCY ��-- �� -�; '- �"� -- � - -- � {'i• • •�•�•� � I hereby afiirm�hat ihere is a Construction le�ing agency tor thc � � • •�2,7�_ performance o(the work for which this permit is issuetl(Sec.3097, -��- 'pERM1T FEE - ' �� -��"` �-�-"' � ����(Sub Totap �� - -- - '� - . - --- � -- �-6 ° G�O c� Civ.C.). �O��'e .. . PLAN CHECK�NG FEE - -. - . . _. . ..� . ._ . O�B C I�8'I - Lenders Name � � � � PERMIT ISSUING FEE. _ -.. . . . .. .. . �� . ._ . . . . .. .... . . . ... ... . ..__ Lender's Address � I certiry that I have read this application and state ihat tne above ��� TOTAL FEE� _ .... . . . _ _ _ _._ _. ,. �,_. . .. ... . • inForma[ion Is correct.I agree to comply with all County ordinances �. � . aM State laws regulating Electrical wiring,and hereby authodze .._._ . .. . _ .. . _ ... . � . . � . . � .. . � representatives of thie County to enter upon the above-mentioned � . . � propert for inspection purposes � SEE REVERSE FOR EXPLANATORY LpNGUAGE--- - - . - - � � � �� -. , '�� � ���5 R7 _ ._ Signature of Perm� Date � i��� .���r,.S_ , :��' .. ;�, : . � !� . �. �._. . .� ..` . .. _ I � Yi_:�� :i�,. ,7'...JJ_� I:')I?, .'.J;0 �. . �. . � � ` 1^ INSPECiORS -^ _, _ '..OWNER-BUIL �` � �_.__ ._� .__..,......�.f'_.._.E .�_ .'.._' __'__'_ ..� . � ' � - . .� _. ,M _._ .... � �.�. �. :� .� �'�•,. \�...APP OVALS�� -,.. I_..._DATE -�-.. .SIGNATURE'_ -� _.. � . '._� . . • . _..�.._ =' TION ��; .._ . ..__ . . -- -----_. ... _" -- ' � � DER pECLARA ,. �: --- -;. -- ; —` c ' '. 1 .. i� �� TEMP.PO�NC- POLE� � Lav�or ther fo lowinc�e 5on($ection4�co'Contraetors Lic�ensc ` �• . �•'•'. , R . . 6us�ncss'2nd � _-„__".�. � . ___' ' . .. _ ' . � UNDEASLAB WORk( -,:' '. . .__._'. �._._ .._. �'__'...._.... ._. . :"� , '�. �� • ...'- Professlons Calol:Arry C7t a County Wbich requires a pamiit . p.__ _ _ .. ." ___."' ___ _ . . , . , .,..,, , ,, . er,inprwc,dcmolish.w mAair vry 5L'uctule�P�ia ' _---__ � . ROUGH CONDUIT� . ..--'- '--�.. .- ._ . . . ` �uch pennit fo �. . .. � . �.. �.. • ' . to'R ssliancer also"reqwies�he appFcvK lor s- t1e -— < .0--.- .. __ .._ . . s , ' f WIRING -�'� � � � . , .. 'e sfgned aWtementYhat he is Ocensed ptn5uant to Mc p�ovis;ons i -+ ��_._.___.___. _.______. . � _ . ._,; . � . , �.. ...- . �l. � . . . .. . ol the Con7acta's'Ucense Law(ChaPtcr 9 fcomrt�encing with i FlXTURES-'.....-� --- .-_—.'.. _.. ----- � � -' i -'l y�Section:70001 0l Division 3�ot 1he Bisirress arid:Profcssions � . � ,�. � . � . , , - _ `-'- - - �-�- ---\�_. 'POWEfl-AU7HOflIZE� : ;"�" �--��-i- :---�����--j . .... --- '� � ,... � . Codel n'�thatheJs�exemptlFierefroin�gnd�fhe'Wsis'far-tRe ` , � -UTILITl��CO:NOTIFIED I � .. '��- allegetl exempGon.�Any violalrm o/.Section 7031.5�by�My �'� • L -.�.`.�� \_.,.\\- NDTES__. \.�. . L�1ZC1'Olt FYOtlt ` .. � -`aPplicant�tor 3 pertnll SubfCcts Iho lippGCan((O a�CMf pCrkVty :flNAL=- ' ���-- ! � ' � � of rrot mae lhan fivc hUntlrM Uollars(3500):� " '`��'� �_ _ �-,:.�_'�_�* _ s'.-♦ .:,;-•��r .,:'� ; ;i " ..��,. �._._ � . � �YSec.t'❑7044n 8usinessedand Pross�tais I C Iode.t'hThe Ca;n�the �' - � �� I , . ..�'.i -, ' - - tor's 1- - - � ense La ot apply to en cnmer of property w bullCs � \ . �\ _, ... .-.- , ,� . - C:. . �. ,. k.__ ._.._=_ _ ...2;•_ � ._ .�_i-.._� __: �� ', � . .. . ..� �� ... __.. .. �. a7nA�'�s thernon,"antl�who does suCh w6rk himself pavided i�,,. \.,,.: ., �: � `.\�..,. , � 7hat such Improvements erc'rrot Ynfendetl or ollered�for sofe:-1i, • . _._ ___ __..___J... ..__� . `.�__: �_ . __ ..'� . . , � .' � �. � � �okl within one ye3i 0/ '- -. _ , , _.._ � .__. __ . . i � . � h�r,�thebulldingorimp�oveinent'is�s c.:._. . . _ .__. .__ '._.. .. . . . ._-. i ` .� c fef�on,ihe owne�udde�v,�iil h��5'burden of provirg�fr6t �-..� ._.._...._ ..=._� ...�."_". ":_�._.._. __...,, - � -� . , .. ...:^. � . _� I . ' � �he tlia not builtl a 1� rove!a the e o!sale) L-_ __ � I-!_ _ _ - _ -� � ! I ' ,.- . . ,., ' � . - 6 . , �' �- �� \ <- � - , � . -. _,. . � �• ,� ` . . .... �� I i .... . � l_•, -. .: . '. . ^ ' , :_i;'li .._ .__-.____'-'_.__...'.._: �,..� .__. '_ ..... . _ .__... . . . ..- ' _ .. . . , ., ,. . -. , _,_._.,,., � � � . � s 1 am exemDt undec 5ec.• �.. � .. ' ----_ _. : - - �, � , - _ __ _ _ . -- �,.. � .. ._. f-� -----. __..._. � � , i __B&-P.C.Jor_this reason r-• � '--�-- -.�.� ...-- --...._-- � i � ril,. ,.. , . ,- � � �-_-___—_.:. .____.__.. --.__.. :.c . ': ,.. _ .. � i . ;.. .� :.,.... .... .,. �. � _' '.___ __.__. ___.._. _ _ a � - :!1 ' ', I .�. � - � • _ ._ . . . . ____•. . __.____. .�. , � . �, _ �__.. . .�„ ": . , � ,. � ... . - - - __ -Date--- . - - - -- _ �, i � , , � , ._., ;, , � _ _ ,.., _,�. ,; '-� . ._, , ; . ' � � � � Owner � � . � ... .... , . .. �� . 4 . ; : ,, . ; ,�� , _ �: , � — - -- -_ -- -- � • , . _ i, , _._ _._-- — -- , � ,�, _,l, ,__ __.,_ , _ , , - —� ___ . �_� _. . , � . � ��� _ --� �, ,. ..� , . ,.. ,. , � „. . � � � ' _. __ _ , . __ _. — ----- -- ,. ., ,,,.. ,� i � I , , — ' ; , ' �---- ------- -- —----------- _-- - ; , . ,. �, , ` — � ; _ . . : . .... . . ...... � ; , __ � _ ; , ——t— ____ �--: — . , \„ ,\,\ � ' ---� ' a_ . ' — —-- : __ _ _ , ,,.. , .. , , , , .. .__... ,.___—----�. _---- � << , _. ... . � ,,,,,, , � . . � . i.�, -�r��',: �' . .�