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HomeMy WebLinkAbout1784A WORKERS'COMPENSATIONDECLARA710N ,��3 �0�81 qpp�ICATION FOR ELECTRICAL PERMIT � I hereby affirm tha� I have a cenHicate of consent b s� � insore,or a ceri�ficate ot Workers'Compensarion InsuranAee.�„�� COUNTY OF LOS ANGELES BUILDING AND SAFETY � or o certified copy thereo�e'cL 3800,Lab.C.) (J �. . . �Cy No��COmppny ���'��` � FOR APPLICANTTO flll IN� JOB � �� R C Cerlified copy is here6y furnished. New Residentiol Bldgs.8 Poals EACH' NO. FEE ADDRE55 � d Certified topy is iiled wilh Ihe counly building inspeo- 1 8 2-Family,Sq.FI. x — S LOCALITY.s'�F (�,f �(,�,�jQ� 1iOn(�C(JOlimCfl�. � MUIii-{Omily SG.FI. — NEAREST �y� ' Residential5wimming Pools OWNE20R „/ �t�r •d � Da1e Applimnl ` . FIRM NAME� �'G i v1 R�G7 ' � CERTIFICATE OF EXEMPTION FROM WORKERS' �+'� �� � � ADDRESS A O � COMPENSATION INSURANCE Oudets:Rec_1i9h1_Sw. r a J� � j�� Firi�20 � - (7hls s�clion n��d not b�compl�t�d if 1h�work fnvolwd by Tolal No.J� qdditionol "—a � � C�TY �.�i �1 Tel.No 99 fb�p�rmit ts for on�hundr�d dollan(SI00)or bss.J - vu N cNeCK � I cerlify thot in the performance of Ihe work for which this nGVtICAM permit is issued,I shall nol employ any person in any monner ��� � �^ so as to become subject to the Workers'Compensotion laws. li9h�ing Fixtures Firsi 20 �U v ADDRESS . . � Total No.� Additional QTY Tel.No. � Da�e Applicam Fized Appliancas No�Over 1 HP - PEemiT NOTICE TO APPLICANT: If, ofler making this Certificaie of . App���� K�„� Exemption, you should 6ecame s�bjett to the Workers' Range_Heofer_D.W._ . Compensation provisions of fhe Labor Code,you musf forlh- Oven _Oryer _W.M.� ADDRESS Q �' �.?'�q(�'��(/� with comply with such provisions o� th�s permi�shall 6e Top _FAU —W.H:_ ' .deemed revoked. � Hoad _Fan _O�her_ �� CITY � Tel.No 2 �j � LICENSED CONTRACTORS DECLARATION �ICENSE OR �hereby affirm tha�I am licensed under provisions of Chppfer 9 Disp. _Room Air Cond. — .—��'3' Closs. REG.NUMBER � (commencing with Section 7000)of Division 3 of the Business � DISTRICT NO. ROCE�D BY . O� and Professions Code,and my license is in full force and eifect. PDwer4PP°�°�us 8 Large Applionces p Size 8 Type HP,KW,KVA,or KVAR � —r'Z L7.C/1��--Q'��"' U � License Number �7�`0��lic.Class V��. � � ' FINAL �� � Up to 1 Incl. � � � Over 1 fo 10 Incl. DATE . 2�,���' ' Conimclor�`� Date °��''d YAUDATION W ❑ Over 70 to 50 Incl. FINAL I am e.empt under Sec. Over 50 to 100 Inc. BY �,� ']u(�A N � B.6P.C.for this reason Over 100 Z � Services,Swbd.,MCC 8 Panelboards � � ��� � �2 � � Da1e: 0-200 Amp.Under 600 V ► � �I • � � 7.Q� � Signature 701-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V . • • � � 7.�0� Exemption for Reg.Malnt.EIeU. ' � SINGLE FAMILY Temp.�Power Pole 8 Apportenances � � Z 2 O.—.S S . HOME OWNER-BUILDER DECLARATION Sign wilh One Branch Circuit - I hereby affirm thar I am exempt irom the ContraUor's License . Additional Sign Bronch Circuit: ' Law for ihe fotlowing reoson(Section 703L5,Business ond � Professions Code): . ' � , . . ❑ I,as owner of ihe proper�y,wil�do the work and the M;sc.�Conduits 8 Conductors � � structure is not intended or offered for sole (SeUion Orher(See Complete Fee Schedule)_ � . 7044,6usinesz and Prafessions Code). CONSTRUCTION LENDING AGENCY � . I hereby affirm tho�there is a mnstruction lending ogenty for � _ . the per(armance of ihe work for which 1hi5 permit is issoed PERMIT FEE (Sub�-Total) /Q � (Sec.3097,Civ.C.). ' . � PLAN CHECKING FEE �' , '. Lender's Name / � � � PERMIT ISSUING FEE - � / O � � ' � Lender's Address �/� � I certify�hat I have read this oppHca�ion ond sta�e thm the TOTAL FEE . � '� above informolion is mrrect.I ogree 10 comply with all Counry . �� � ordinances and State laws regoloting Eledricpl wiring,ond � � . hereby aulhorixe represenlatives of Ihis CouNy to enler upon - . ihe abov -m ntioned propeny tor inspecrion p rpos � �/��/ � � �� SEE REVERSE FOR EXPLANATORY IANGUAGE - � Signature of Permitlee Da e � � �'"r , . , . , . r . , p ' i ' - .,. .. . . . ', .. ; ' , �. .. . .. . . � .. . '".. . . .. �f, . .. . . . . ' . .. ,. . . .. � ... ...•. ....� . . rc K . .._.-. . ._.. __ _ , - _ ILDER DECLARATION� ' . ..\. � - .,. _, ��AFrRUVi.LS ___DATE__� SIGNATIIQE ' -.. . _ . ..... � . . :-_ - . .. . . ... . ,. .. . ��... . .. \ � '. TEMP.�POV�(E7-�'OIE.. -.. ... --- --�- .------ ����. .. ' . . 1 he�eby afp mNha��l am exempt from 1he Con rac�or's � .' � .� . ' t � , �..:.. . .: .. �...v� ��`� � . . __ _ . ._ .... . . ' �. . . -.'� .. . . li[anso Law {or tne.follawing reason.(Socbon 7031.3. . -�-'� -- r - ' � UNDERSLI_.B N(02K�i _ � - _ - ,, .. --� � Bunlness or.d Prolesslons CodeJ:Any city ar rounh�wblch � �---- � - �- �� ROUGH COhDUIT --- - � :' - ��� �. � �� � � raqvfros apormlf fo mnsfrucf,offer,�mprove,demolish. .,� ;._ � ,,,,� '-- -��� '� ' -�� -�� � � � , � � or reoolr ony slruefure,prlor�lo Ils-7ssuanra,o�so re� ----�� �- -- - � V�iRING"�''� -�� � =-'��• � ' , , � quiros fho app�lconf forsuch permN}o(tle o s7gned slo�a- ; +.•,r'S�-� -�-- �-��, . �- , . , ::,, - - � - '; � ment thot ho Is Ace�medpvrsucnt�o iho provls�ons o�fhe _. . .... �.. ... . _ .FlXTURES' � .. ' ^ . .. ' - ___ _ -. . . ,� ..,. , , ,.:. ���, � �i.- _. . _ . . ..� . � T.:, L nUn with Confrac}or'� krnsc Law(Chap�er 9(cpmme g ' � � ��- Secfiort 7Q00 oi Di�lslon J of fhe Buslneu ond Profes- ;.. ,.��_ ._.G.. ._._- __ FOWER AUiHORRED.- - � -���- '�� ' ` ���` � � �- , zlons Codo)or fhat he 7s exompt therolrom ond the 6asis ^�. UTILINCO.NOTIFIED.:____ . -.. � . � . /or tho vllrgad.exomptlon. Any vlolotion of SecNon ` ---- �--- ��-- - -- .. . _' FINAL n .. . c� -�'-- �� �� � .�.. , . . ��:..7C31.5 by any appl(canf Ior a perm(t sub(ocfs�hn opp6- � .__. C.i�(ci nrs yionf� -, � �•• ',\ � � _ � tont fo u dv(1 poncl�y o/nof morc fhan/iv�hundrad .__ _ _ .__... _._.__.. . ___ __. _ ,. . ' � NO7 5 �'��� � '� " " �� � doflars(SSQO).: . t -.-`,\r.,�.'...� . �-�\1 .. . _ .. .... - . . . .. '' . � . . ...--.....��I,as owner a{tha propeny�will do Ihc work,ond ' �Jho sirutture is nol infendad or otfered far sale. . , -..:`_,, . �.` '". .,.C , _ . �. _ .. . .._ � .. .. . . . . .(Sec.7044.8os�ness andProloselons Cade; �ihe Contrac , , .:._. -_. .�._ _.. � - ','.--- .--.. . . : . for's Llcenso 4ow doez nol opply to an owner of proper�y � .„ .����•�.�..; \�;' - . '�. . � �, . who bullds or'tmprovos fhereon, and who�does euch � ,., i�.: : � ._� . . , r�-' - � '��'"- � —- � ��---��`� �`"-- '�• -- � - � - � � work hlmself provlded thaf suth�lmprovamenls are nc� ;i;.;. - �� �� ' " � . '.� ..-. '. -'•. . '"-'�'.� ' : -� - - � '�-�-. -��" � � � � ' � � -� Intanded or o�fored for sale.IL however.}hv bulfd/ng or � ,�., . ... ..._........._.._._:"-'_. _.......� _ .._._. _...... . � ��.�mprovement i�sold wuhln ono yeor oi tompleflon.Ihe � . . � , � ` ' ownar-bWlder wlq fiave tbe 6urden olprovingihat he did �� �- - ' -'- � � � ' ' ' � . '�'rSot bvlld or lmprovo�fo�fho purposs of sala.) . ,.�, _r��. � . , . .. . - ' - ,_: �. ., ..� � ,. � - : ` -. . . � . .. .. . . �. __.__ .� : . �.,,.. . . . . . _. . ,._ __ . � .' +� , � - � .._ . � .� { m;exempt�nder Soc. �.�. ,,� � . , . ._ 51...,,. . , .., , , _ _ ..: _._ ; . . � - _ -... . , , ,-. _ . -- - , •. _ , , � . . ' � _ . . __... _ _ _.�' , ._. B.&.P.C.fcr.thisrcoson . . . � ' ' . ...__- _--� - - .... ., .. � ,.�, . ;,. . ,_ Oate- . - - _ . . , '� - . Oavner . . . - � � � . � . �, ._. ..... � "1 f - - -' . . ,` �.,��' '-� .`C� . .. , , �