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HomeMy WebLinkAbout1654A 'JORKERS'COMPENSATION�ECLARATION 76A663 ,o,e, APPLICATION FOR ELECTRICAL PERMIT - {� ,,,rirm that I have a certificate of tonsent to self insure, CE-ao6G �rtincate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY LI r�ther (Sec.3800,Lab.C.) �}�� � � PO�Ifcy No. ��V Cpmpany `� ` '� � . Fqi APPLICANT TO FILL IN . .. ... JOB �/c� . '�, -L Cer�ifletl copy is hereb fumisheG. :EACH NO. �FEE �AooRESs � V y L Y New Residential Bldgs.&Pools � �.�Certifietl copy is filetl�wi[h t c nty build'g inspection 1 8 2-Famiry,Sq.FL S — $ 'LOCALI7Y �1�,p.t�� � . d partmenL � . Multi-family Sq.Ft. — NEA�Esr Residential Swimmin Pools CROSS Si. Dat�Applicant -__. OwNEH OR ;� 1:' '�t: FIRM N0.ME �'Z.�RTIFICATE OF EXEMPTION FROM WORK RS' ,. Outtets:Rec�Lght/Sw v/ .� M�� ;�+�� ZL, � .COMPENSATION INSURANCE � . . nDoaESS �(This sectbn need not he compbletl if tMe work Involvetl by lhe Frst 20 � permit Ia for one huodred doltars(E700)or less.�, - Total No.� qddilional �CITY � 7e1.No. �1 cer[ify ihat in the performance ol the Work(of which�his permit � - p PLICANT� , is issued,I shall not employ any person in arn�manner so as to . become su0ject Eo the Workers'Gompensation laws. Li9hting Fix[ures .First 20 �ADORESS�. ' ._ � � . �� . Total Na.� Addi[ional . GTY . .�. . .� Tel.No. date �Applicant Fixed ApD�iances Not Over 7 HP . NOTICE TO APPLICANT: y, alter making this Certific�te Of ' PEFRIIT . Exemption,you should 6ecome subiect fo the N/orkers Compensation Rang�_HCatBf_D.W. _ APPLICANT ,provisions oF ihe Labor�Code,you must forthwith comply with such� Oven_Dryer_W.M._ � � � � � ADDRESS a� � �`�(� _provisions or this permit shall be deemed revoked � � Top _FAU _W_H._ � LICENSED CONTRACTORS DECLARATION Hootl—Fan _ Other_ -� GTY���� � ���T .No.$�;31�� I hereby affirm that I�am licensetl under provisions of Chapter 9 p(sp. __Room Air Cqnd. _. LICENSE OR /rf�( ICommencing Wilh Section 7000)of DiVision 3 of ihe BuSineSS antl REG.NUMBER V � C�az'. Professions Code,and my license is in tull lorre antl effect. power Apparalus 8 Wrge AVPliances DISTAICE NO. . '� PROCESSED Ry . . _ I� ' �� � TA[� Size 8 Type HP,KW,KVA.ar KVAR . ' C`�_�` License Number v� Lic.Class *""� � Up to 1 IncL� " -� - -- �� � D TEL �!� � � � _-+ ��Q� Over 1 to 10 Incl. "-`7�� �� VALIDATION O � Contractor_�`�" 'v`+ �— �Oate�_�� � �� Over�10 to 5D Incl. FINAL U ❑ I am exempt under Sec. Over 50 to 100 Inc. gy W _ • a � B.BP,C.for this mason Ovef 100 ,. Z - — Oate: � Services.Swbtl.:MCC 8 Panelboards. . . . , -. .--. ... . . ; . . .. .- . .. ,_. 0-200 Amp.Under 600 V SignaNre -- �-�201-1000 Amp.Under 600 V�-�-�� - --� � � - � - � - - � ��� - ❑ - � -- -- - - - � - ----� Over 1000 Amp.or Over 600 V � � Exemption for Reg.Mainc Elect � . . .. .. _ . . . .. _ . . . � �-������- - � �SINGLE FAMILY - � � � - Temp.Povrer Pole 8 ApOurtenances - ' HOME OWNER-BUILDER DECLARATION Sign wi[h One Braneh Cireuit � ' 1 hereby affirm that 1 am exempt trom the Contractor's Ucense Law � �� for ttie following reason(Section 7031.5,Business and Professions - Additionat Sign Branch Circuits _ ., '�� 6.5,/1 A _. ... ..�... .. . Codc): Misc.-0ontluits&Conductors � �- � � � � � � - � - ��� � ���� °�2 ❑ 1,as owner oF ihe pro0erty,will do t(e viork and the structure . O[her See Complele Fee Schedule)_ • � � (�5 0 is aot intcnded or olfered tar sale Section 7044,Business � ► ;� � and Protessions Code). ... . . .. . . . . . �. .. ... . . .. " . . ... . � CONSTRUCTION LENDING AGENCY - � . -� � � - - , � ° ' � �S O� I hereby atfirm that there is a construction lending agency for�ne � . a 9,1 9—8 8 performance of iho work tor which this permit is issued(Sec.3097.... pERM1T FEE- .� �-�� � � -� --(Sub-Totaq . -. �. _ _ . . . . . - Civ.C.�. . �, .... .PLAN CHECKING FEE. .. . . ... . . ._ ._ ��, _. . . Lentler's Name � � � � � , .. PERMIT ISSUING FEE . � IQ _ , Lender'�Address . I�'�O -..... ..... ,... . . . . . . . . �I certil that I havc read this application arW sta[e tlut ihe a6ove TOTAL FEE � � � inlormalion is cortect. a9ree to comply with all Counry ordinances . a�d State lavrs re5 ����9 Elec[rical wiring,and hereby author'¢e ' s tatives of �s Counry to enter upon the ebove-mentioned � " � � - � � �� � � - � � - �� '� - � �- - r for ins n purposes. . ,SEE REVERSE FOR EXPLANATORY LANGUAGE . . _ : �'i5-�8 Signature ol Permi _e � Dale - � � ��. L �r :�a. .�.,_., „ ,.�.�� .. . . ._��. t .._. � �f.F�.'�.1 . i' ' , , - �-- __.._ _.. , L 1 ` ` ��I ( , 7CMP POWEq POLE��- i_�_ SIGNATLIRE � I , j. " � �1� �� �/ AFPRqVALS OA7E -�NSPF�TOR'S -�� -- --- � - -- - � - -OWNER BUILDER DECLARATION � ' _ i ! � - ..' ..,, . , � . ..., � . r � I hempy affrm th�t I om ezempt from the Contmctors Uceise ___ _-".... - . /UNDEFSLAB WOFK : �.. �..___.... ..�:. _ __._ -'_ _.__.__ ��'��'�. ! r Profe5si0ns Cfodo)�Arty Cty pr c�m w0 nf�ul&Sula p�d �.. ..-�-- -_- - - .' . . . -. . . . .': .- . r to corsWct;a!!ef i rtpfovc,demolish,or rcpsU ary stticlum p�ior t,,.EtOUGN CONDVIT �-.',. O '__'._ ._ _ � • \ ..._ �ts issua�e a!o re u ie., he a ficyrt kv such�c o Gle i i. .--.� �r _� ` ;'. W'RING.-';�1 i� ..-.'.� -.�•.' ,�� � ; �;.._� .-�.._S `�,-� .. . aosignetl sdfcmmt thn�ho rsilicen�pursuvrt to Yhe P��'(��s�`'� .___.— ..___ . �. ... • ... � � 'FIXTIIRES , ._. ,_ ._ ,; _ � . � �.��. � ! - ` � _ , . of the Con6acror's License Law(Ch�pter 9�commenc,ng wrth . 1;1,� V. . ,. 1",. � , i ." . ., .. . :', - ' ` .�,� i ��_ . ��..- � � ��"Section 7000 J a7.Drvision�3�o!!hc,Business and Prokssims . __.___ . _. _.__.. _ ... . . �� � . . . . i POINER AUTHORIZLD.�� j � j � � Codel or�that hc is exemp(fherof�om oixl the b,�rsis lorYhe t----�- - --' —�--- UTIUTY CO.-NOTIFIED�� ' � � -. I . � .. �i i ; • _ i ` .. . ..... 4 ,'�.�� �P�f la or�mutnsubjeets the�l Slcent fo a3eim�l Pen�y P� aPP i------ �"� �---�� � --�' -FtNAL���� '������-'�-"L77fCY 011.f'YU11t_.. ' ' � � o/rmt mae fhan livc hundred dolCvs(5500)! . ._.__ _ �. � . ; ��--�---�-NOTEs------ � � � � � �--. ' i ❑I,as owner of the propeily will do the work and Ihe �-J�� � ' ' ' � ---strudure is rrot intended or;offered tor sale.- --� � � � _ -. .�T t';^ �-.r,:'.%.� __ - � ��,� ' .. � ��(Sec.7044.8usiness.nd Pralessia�s Code: The Contracto�'s . .:�..� .l , ., .l .� . �.. ,. ...� -, .�. .,�...� , - �.:,. ___. .. _ _.. License Law does not apply lo en o�mcr ot prqpertY who D�ii7ds `.,; "__- --- -..---� ='-- �-�-�-<- ' ��- .- .. . . �.,. � � �� �w imPioves thweon,�and who'does such�work himse7l povidetl �^:' �� ,__._ , _, � ��„� �,,,,,_:. _�, - � , , ,. Ihat such I nprovements are nof iNendetl a,o!/crcd lor salc.fl, \__ . _....� . s ;:_�: .`_. ,,_. :.: .... ... .. , , _.. . .. .'' -.._ .. ., ..,havever,the budd'ng or improvement is;sold within rne ye✓o/ r'' . ,. , . ,..� , . - ,..____....._�_.,_..._.........._�_.__._..__.�.'__....'_'._'___. . .canpJe(on,fhe aancr-buildcr wr7(have Ihc btndCn�ot p/ovinc�,}hat I . . -. ,. . y � � � � �he did not build or im,orove!er the purpose d sale.) � � � , � .. . , , •. � i:.� �'• / .: . / � ; .,I � I � I ." �. .. _ -, .. . �.. r- � .� � '� . -.___ -. ..- „_._-_ .._...___--___ '._'. i : . . . , , . . . � . .. - �, �, I - .. _�. . . . . . _ -... '.. � ... .. .. . . _. ...__�. .---� ; .� . i ,.... ,,� . ., . .. _ l ' �;"•` -- =1 am exempt under Sec, , � , c: � _ �,.if--_ ._. . _ _ __ - -- . . .. . _ . , li. . .- - ��-B 8 P.C.tor this reason - . , , - �,. _ . . . � _ � � . ,._---- ._... .--..___, ' _ . . �� . . . � � --- - ---- __._.. ._ . „ .. .. . . �ate , , � .. . � . � �. . , � � .. . ., - Owner � � � � � , � . .�... . . �.�:. ,-.�- ��:� . . i � � :. , -_.. _.. . , ._---- �--..___ _ -- � ,�. , . , . . -- , , . ... , . . . . . � . . � . „ , .. -.. -� ; ,-.� . . . .. .. t__. . _ .r .._.._--.._.. .�.-- -.._...._ ._-- . . .._- --- - -. .. �, . , . � ��- . __ _. 1 ' i . .-_._ ___ . _... � ._ _._ __ ..__ ._.._ .. _. �. . ° . �.. . ., ,. -. � ,. _._.� .__._ �'_'.". ` ,.t . . . . ..: ,�, �.. . � , . � .,. ... , �. _'_.. _. J _ .. ... � � _.._ ---.__ __. _ i _. � , _ - -._... . _. _ _--- -- .... _ �� , . . � .. ... :�..:... .. .. ... . ... . �_. . : . . . . r.,�..`.., . .�`i'�.. �. ' ._�J ti . , , . � , , . ., , ,,�;-� .-, .___ t . _. _,