HomeMy WebLinkAbout0772A WORKERS'COMPENSATION DECLARATION 76�7 IOiel qpp��CATION FOR ELECTRICAL PERMIT �
I hereby offlrm Ihat I hove a certificota of consent to self CE-806G {�
insure,or o c?-�l!�mle of Workeri Compensation Insurance, � COUNTY OF LOS ANGELES BUILDING AND$AFETY I'
or o c"e�rL�`ie�8 copy thereof(Sec.3800,Lab.C.) � . U
Po'�Cy rvo. ����Company �•Y1�rr�r�-r �. FOR A►PLICANT TO FlLL IN JOB
�' Cer�ified m s hereb furni:hed. p p�0�-Z-� EACH NO. FEE. ADORESS ,z,j
PY' Y N � New Residenlial Bidgs.8 Pools
� Cer�ified copy is filed wi�h�ha county 6uilding inspeo ��8 2-Family,Sq.Ft. S — E IOCALITY
fion departmeM. � ��Mulli-family Sq.FL — NEaREST
CRO55 ST.
Date��C Applica '� ResideMial Swimming Paols pWNER OR
� �� - FIRM NAME �
� CERTIFICATE OF EXEMPTION OM W RKERS' Oullets:Rec„�_Light_�Sw.� ' �`''�`��
� COMPENSATION I URANCE �( Firi1 20 AD�RE55 � •
(This�atien n��d no}b�templNed II th�work involwd by 'Ta�a�No b qdditionol CITY el.No
Ih�parmh I�Fer ona h�ndr�d dollars(5100)or I���.)
PLAN CHECK
1 cert�fy�hot in the perforrriance oi�he work for which rhis � � APP�ICnNi
permil is issued,I shall not emp�oy any person in any monner
so as�o become subject fo the Workers'Compensation Laws. LiqMing fixlures First 20 ADDRE55 •
� - �� To�al No._�� Additional QTY ����
��.No.
Do�e�./R� �applicam ' Fiked Appllontes Nof Over I HP
NOTICE TO APPLICANT: If, a(fer moking Ihis Certifimte of . PERMii
Exemp�ion, you should betome subject to the Workeri Ro^9e_Hea�er_D.W._ . APPIICAM
Compansotion previsiens ot the Lobor Code,yo'v mvsl forth- Oven _Dryer _W.M.� ADDRE55
i�h comply wiih such provisions or this�permit sholl be Top _FAU —W.H:—
deemed revoked. � CITY Tel.No.
� LICENSED CONTRACTORS DECLARATION Hood —Fan _O�her_ •
Dis _Room Air Cond. — LICENSE OR
I hereby aHirm tha�I am licensed unde�p�ovisions of Chapter 9 , P' REG.NUMBER / Class. � }
(commencing with Seciion 7000)of Division 3 of the 8usiness power Apporafus 8 lorge Appliances DISTRICT NO. . . PROCE55 BY n.� _
ond Profeasions Code,ond my license is in full force and effect. Q
. � Size 8 Type HP,KW,KVA,or KVAR� 1 U
License Number��9� Lic.Class �"� Up to 1 Intl. FINAL �
CoNrotlor i��hr'i^�J �m��� .,L+ /�f1trQC Over 1 to 10 Incl. DATE � � YALIDATION �
O Over 10�0 50 Incl. FINAL W
_ 1 am exempt under Set. Over 50 fo 100 Inc. BY 0.� ._
OYGf I� �
8.8P.C.for this reason Z
� Daie: � Services,Swbd.,MCC 8 Panelboards
� 0-200 Amp.Under 6W V . �
Signature 401-1000 Amp.Unde�S00 V
� Over I000 Amp.or Over 6W V _ ;
Ezemplion for Reg.Mainf.Elect.
SINGLE FAMILY Temp.Power Pole 8 Appv�tenances ��
� HOME OWNER-BUILDER DECLARATION Sign with One Bronch Cirtuil �
I hereby affirm tha�I am exempt from the ContraUor's Litense qdditional Sign Bmnch Cirwils � r;
low for the following�eason(Seclion 7031.5, Bosiness and ,_U 7�],��
Professions Code):
� Misc.Conduits 8 ConduUors .i�• • � •�2 ,
I,as owner of Ihe propeity,will do ihe work ond 1ha
structure is not iniended or offered ior sale(Seciion Other(See Complele Fee Sthedule)_ , . I � � ,� �7 5
7044,Business and Professions Code�.
CONSTRl1CTI0N IENDING AGENCY •+ e � 8.']��.
I hereby affirm tha�there is a conslruction lending agency for
ihe periormance of ihe work for whith fhis permil is issoed pERMIi FEE � (Sub-To1al) � ��.� 8`8 b �
(Sec.3097.Civ.C.).
PLAN CHECKING FEE � � - �
lender's Name �O
PERMIT ISSUING FEE � �
lende�'s Address � �
I certify thot I have reod this opplico�ion and sfate thot the TOTAL FEE ` .
above information is correct.I agree ro comply with all Co�nry . � .
ordinances ond Sto�e laws regvlaling Eledrical wiring,ond . . . . . �
hereby authorize represenlatives of ihis County fo enter�pon
t -mentioned roperty for inspection puiposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
` f-?/R�r4C
' noture Cermiitee �ate ,
y- = � �
' ,. ,
� _ _._ - .. .._. .,___. �., ... ._. .
� �( ` 1�_�4_ ,_ i
. } : ' � i:. F � . � I ,
/� ._ :! � i �� � .
. �, !� j.� , ; , �
! ' t . ;
. �I� t` � . -ri (' I, � '
�- � �. ` t� ', ,�� �', I i �'� !
. r ;; �, � , � ; , ;
, . _ ., �� ' .
...\ i` �, _ , , + , �
-- , � �`, ; �, �; i ` � ; _
i �%
� , , . , �i, �.L' .n �C �v T r � C. rt - : ,.
� i+ �,�' ;O Z 'a Q X ,�� O Z' '' .
� � ., ' ' ';� I.� �-� n`, 'C Z � �m ','v ` ..
. . � � � �,in ''O �� � 2 � .� ''� ,
� b c^ n � O „ _
i ;� i j O c i. � w � i. '
i, � I j :7' T � i; 7 � z� G, i' .
. - �• � Y.. O � �
" O � C O 'a' 'D
� � '� N I' 7v � r
� ''� .1 �. v^ O i� -1 TG m � �.. .
� i
_ . , . (� � ,.I �' �. .
.
�
'„ . ' " i. ..' Q �,
�
� � .._ ��r . :• , � i,
. . . 4... . � -.1, .i. .' ._ ., i. . ... O, �I _ � ., .
i i i � � i .
{ . '� . , . � , , � . . ... . . , '''� � ' , ,O� �
. ' I � . • I i � � � � � � 1
_ i I : . � ; � I , � 1 � � � ��rn
�
t -. i
i � � � i � � � j I C � � ,� '
,. �
,�, . � � 1 , 1 .. ' � . i .
. � j n. I �
, : � � I t � i ; ._ _._ _ - - - �
, _.. .' i _..I, _. .i __ ' ', ! '� ��� � I R
r
�. � .. i � � . � ( �' i 1
• ' I . . i �� '� � � `
I �
I '
� . • I � .r ._.1 . .. ..... .� . . _ _ ._ . . - . �
} � 1. I 1 i I � i.. '. , ..i. i , �lU 1 M ,
' . i � I � I � � ' � i � �`D^ h�
. .
� � i � � I I I � I i I � C r.
` {-� �� - -.�. _..1 ' . _ . _ ' � !. _ __ _.. _. • � _ � �, -
� � I a � ; ' - I T f'r
E � � I _ M1
+, � i i I . - _ ,, i _ ., I. � .�
' i . (. , . ._, , 1, ? � i T 1
� j i I _ .�� . � , '._ � . :i , ..
: I ' � . . . I '. ' .,f r�
. s, ; � 1 � � _ ` .. � ,
� � j ! ! . - - . � - . , '
: � - � � _ ;
' 7 I I � I I '_ I I ; . . I ..
�
� .' i
, � �
�
i
. � y
I[ . � i ' . ': i ... i i . .. _. , �
t i � I � _ I j I' _, , : `
; . i :. : . . ',, , �
I ._ .. ._ .. _ . .1 i. .I �l .i. � - .. `. � '` �-;
�.1 , � - , � 1 i �� . I , „ �• � ',
�'�' . i - O �? 'w �.Q�,�o ° � � F F o'i.�4 .o 0 oa'". �n3.n o 0 i�� . ..
�' ; - � �, � 'k� �v m o �-ti m �� , .'. �' o.'� � � � H � T
,• ' � � � ; ; b i�3 �'�e7, � � x-O �^ a - q „�a.; :,�o'�'` c -� " . ,
. j c� �p � c . o.�.o-_. � ❑N i^? o «a ti N "
� , (1 � x J--.C.� ¢ - c � o' _ � d.�O.Q? n �-�q N N:��, i• �
�/ . ,� , � n,� cL 3 • c .s. _ w n�c cL�+n' � y '
� � � � � , • . p � O a a 3.Cn.c i„ Q ,p� �'Q O Q�C�' , , �
111 N �' �p O!1 C �.. �' O �J �
i'+;� _ - � ; , • I s (' � ':U ' H ov � n �� f�'=c °'� O�n Nb a 3 �0 3 ,�`t .
' , . . ` l , ! !^ �. Q o F p ��v Q N... �i j�0 ° O° ���c�' � =.o � '
, . i� d,o ry sa',,,a� � �"�I n.� k 7'<'.m � � o
�_ , . � . .. � p �.'� �/T< p m D M � N Q � � ��.i� r�m o`,C, pn'� p _ ' � . .
' � O }✓lVf ; m E � d� ' ,4 7 T � -�..� 'u:O•� O.N 6.7 H O p C ' .
1 - � � ..n �' _.�-n �-'^ Q 'o m ID o ' .. � �'f v � �" n 3 '
� t I '. � . - � t�° � �° �.o o a''a a ° j'm wn« 7��c o'� m, �
;� . . , ��. � , .. . ! , '�� o-�� •:.[�A� H ��; '�b � � Q O� � '..'�...�Q �' '.p .
1�, `'a �� T�-o� o� 3 A j �-� � ' � 3 �'TM`
o '� m 3 o D�, v
�' � n' �
, r� . . I , J .. ' - i , ✓ ��NynF � � ON .Qf:, � 3Km,��O : N � �ip � �� . .. �- �
, .. , � �J� n � n�_. . i� .c ,�.'O,ti_. n:� o �7
�',,�J� ' � : � Cwa �','�° s °'� moat o�oo� $.°o �w�a `� � 3 D i
. „ � -'� � nc $ Q�E � o,r:' Dm 'o'3 � '3ooc�o ° e J O.
... . . . � ' " .. � . , , �' 9 7 � �G N O m y 0 SI�, +� �.[� � �3 C N 5'� n n � z •
r . ; ', `"�,° t'N c°.�e� Fr• `o � o a�;� a�Q Q� j °' -`�•
r� - o`D ov n- o!i' a�"'3-a� � 'D o:� � ..
o` _a$ N o o . �;r: c �+�e vw M'�3'� "n
'.` � ,�? � ? `"mi ' �o,� o-ro ^'o° F �'ooN. iw^ .
� +� `. . ,. __ ' '. .. . _ . � , a¢° ° �.�,'c ° ' �a'. a'•� M �'�-e�m �a T�,i�:�` �_
; i',
