HomeMy WebLinkAbout1257A (6) WORKERS'COMPENSATION DECLARATION �� ���� �o,e� � APPLICATION FOR ELECTRICAL PERMIT � � �
I hereby offirm tha�I have a certificate oi consent to self �'8�
insure,or a certificote of Workers'Compensotion Insurance, COUNTY OF LOS ANGELES a BUILDING AND SAFETY
or o cerliLfie�d co y Ihereaf(Sec.3800,Lo6.C.j �
P❑ol�i[y N6V•P�1S.3/'Comppny FOR APPLICANT TO Fllt IN . �� :7 �G T
Certified copy is hereby furnished.� , New Residenlial Bldgs. Pools EACH NO. FEE ADDRE55 pl� /I �D/
Q Certifiad copy is filed wl�h the county building inspec- I 6 2-Family,Sq.Ft. E — E OCA��TY
— NEARESi
tio7_n dqe,p�a�rtmenr. � n_,. � Mul�i-family Sq.Ft. cR055 Si. �✓ i
Date,l��Applicanl ,l��� ��- Residenfial Swimming Pools , OWNER OR
��. ' FIRM NAME S
� CERTIFICATE OF ExEMP710N FROM WORKERS' Outlets:Rec�LigM�Sw.� � �'��
� COMPENSATION INSURANCE ADDRE55
Thls�Mion nNd no4 be eom I���d if�h�work�nvolv.d b First 20 �
� o Y Total No.� Addirional .. CI1Y . _. _ . Tal.No.
fhe pormil t�for on�hundnd dollan{5100)br less.) vlqN CHECK �
I certify thnt in Ihe pnrformancr.of ihe work for whlch lhis � pPPIICAM - �
permil is iss�ed,I sholl nat employ ony person in ony manner �
so as to become sub�ect to�he Workers'Compensation Laws. Lighting Fixlures First 20 ADORESS � � �
� �. � � � Totol No. Additional CITY Tel.No. �
Da1e �pp���a�� Fizad Applionces Nol Over 1 HP PFRMIT
NOTICE TO APPLICANT: If, a(fer making ihis Certifitale of � APPIICANT
Eaemption, yau should become subjecl to the Workers' Ronge_Healar_D.W._
Compensatlon provisions of ihe Lobor Code,you muat fonh- Oven _Dryer _W.M.— - - ADORESS
with tomply wilh,such provisions or 1hi5 permit sholl ba Top . _FAU —W.H.—
deemed revoked. � Hood _Fan _Othar_ ��TY D/�O/►� �Tel.No. _
LICENSED CONTRACTORS DECLARATION ' tic�NSE 02 ,/�
I hereby affirm�hat I am licensed under provisions o(Chap�er 9 Disp. _Room Air Cond. — REG.NUMBER �7 � � ��0�•C'��
(tommenting with Seclion 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY
ond Profeuions Code,ond my license is in full force and effect Powar Appora�us 8 Large Appliances . . ^ ' �� ��
. . � Size 8 Type HP,KW,KVA,or KVAR� v O
license Number lic.Closs - � Up ro I Incl. � � FINAI - V �
Over 1 to 10 Intl. DATE � Zl���`, VALIDATIOH � �
Contracror Data Over 10 to 50 Ind. FINAI ~
.❑ I am e:emp�under Sea � Over 50 to 100 Int. BY �_ � . .. .. . � �.
8,8P.C.for this reazon - Over 100 Z
. . ..pe e, Servites,Swbd.,MCC 8 Panelboaids � � � �1 .��7❑ �
0-200 Amp.Under G00 V - ��'i• • • •�
- Signature 201-1000 Amp.Under 600 V � � � � �
❑ Over 1000 Amp.or Over 600 V � • •(;[.Q�j
Eaemption for Reg.Mainl.EIecL �
— SINGIE FAMIIY Temp.Power Pole 8 Appw�enances �• '�•��.4 J= —
HOME OWNER•BUILDER DECIARAiION O z O 7—B�I
Sign wilh One Branch Circuif .
I hereby affirm thaf 1 om exempt from the Controctor's License Addi!ional Sign Bronch Cirt�i+s� � � �
Law for ihe following reason(Set�ion 7031.5,Bosiness and � �
Proiessions Code): ,
❑ I,as owner of the property,will do the work and�he Misc.Conduils 8 Conduclors � � � �
structme it not iNended or offered for sofe(Sec�ion O�her(See Complele Fee Schedule)_ , .
! 7044,8usiness and Professions Code). . �
I
CONSTRUCTION IENDING AGENCY - � - �
I hereby afiirm that there is a constrodion lending agenry for .
�he performonce of�he work far which ihis permit is issued PERMIT FEE—�� � � � � � � � � � (Sub-Toial) -- � � . . � .. . . .
(Sec.3097,Civ.C.). �
� . � . . PLAN CHECKING FEE� �� � � �� . � .. . . . . ,. .
Lender's Name
PERMIT ISSl11NG FEE . .. _, . .
lender's Address �
1 cartify tha�I hove reod this opplimtion and stole Ihol Ihe TOTAL FEE, �
above infoimotion is correct.I agree to comply with all County
ordinantes ond 51ote lows regulaling Eleclriml wiring,and ... . _ ,, . . .
hereby outhorize represen�otives of this County lo enter upon • � � ' '
�he a6ove-meNioned property far imp ction urp s. � ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
7-30-�7 �
Siqnature of Perminee �Dare � �
�
l I . .. .
-� ,
. ,,-, '' 1 . , .
t
, . . .. .. , � '
�t T �- Q Z �
. �.'. z T � O � A .� p :° .
, , �,; On+ � � 7p m n' C� y O � , .
7n
U+ � G N� .Z � A 'O
x c o $ � •
. •, p' p =� � m N
i � � �
i� .
o ,
�
`� . A
, ; r�. a
° y.
a m
� �1 � �
i ti
o .
� • � � �
«.-
N .
. �
�
G
A
m
/ -
�
, ., .....
..�.--��'"_ _ - ' ,
i
1� , �.
'� ' �r:_ --
� - N v+t�3 c �� _m � .
1 � : ,0.Q o p o o`� a � � c � . . ,
0 0 �
£ Q N m Q .3..u � O N p .
`� � � � � � � 3 ?.o o N� � � in m C�� �rt 7'4 p n Q o, � ,
�' o =�� 3 �c' ��+��'" � v n."+o ° o'� � � ^^ O
� • � ' . � 4 � � � C' Wp�7c7AC0on � �p0�0�.,�� 3 �� �� . .
' � . 7 � C� � � �'�� � m �^ C �m•OC�K�" 0 .0..m �O � '� O S p �..� , .
�� . , ^ 3 �.�T O .."i.O Q N '^ C •••Z7 b ���N � ,�r,A Q N � .� � . .,
7 7 7 �
° � 3 a m� f � o o ��O x �-< `° '" o� o �0 3 O
�, � �O �N CY <� p N � � O O W Q N�Q N D Y N
t 1 . . N ¢ < S C.�0.O u 7 m `C .�..'�p � 7 �G �Zy C p �.X 7b ,
fj ' m Q O � C p„7 7' p, X W.-. S�.�a.7 f� O
�. . ,. . ' Q OO � NQNrt��ro 3OJp �SCWOOv� % � ".
� ,_ , N -, T a- 3 o p �
° � sm�o°Tv° Nav °� D=Tt' � 3Qm� o '�
� ,� o'o '^ mv '" Qm 3m � Tmo o .- _'„� ° O ,�
� � � �� o�o Z o3< p � � �N �.� � �
� � . . . . . � � �� T�,, o � o � � c �c �' N��' . .
� . . , o �m £ 3c ° na£ � ° � o �vaco � mm �
'�'� . , m °oQo•ao �op ��03 w3 ,°� '^ �.m � oo .
� • o,'n -..� e f . ...�� ° o m =t° =° n.� � �
. . � - � .N O t1 m '.ry a S � yi p.3 � O m O� v^ .
�� . . .. . . . � 3 3 l� � � p S m � � T�7''�� � N�^,O F W� .
' ' � � � m�N O'O fl � C p m Q,O "�� � i+ tn ,�; .
, . � . v S� �. m O 7�" 0.'O = o ��p�7'm m�S S'
. ` ' ' .. � O �� N� � Q y�Q N N =�
, . . . . S� 7 m tn W 7 � :' � � .
. . .. � ' � �. � . . � � � 3 � � n ¢ ' O.
. , d�.0 p S<.�
�Q ' ..
.t .. ' _ ' , . ,
!x �
�'