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HomeMy WebLinkAbout1294A WORKERS'COMPENSATION DECLARATION 76A6N IOi81 APPLlCATION �FOR ElECTRICAL PERMIT � � I here6y affirm ihat I hove o tertifimle of tonsent fo self �E'� . �nwre,or a certifica+e of wo�keri Compensafio�I�swonce, COUNTY OF LOS ANGELES BUIlD1NG AND SAFETY or (/,er+��ed opy thereof(Sec.3800,Lob�.C/.J � �. 0���9��Company �7�� _ fOR APPUCANT TO Fttl IN J08 � Cert�f�ed copy is hereby/umished. New Residemiol Bldgs.& EACH NO. FEE A�ok�Ss � Cerlified copy is filed with Ihe counry building inspec- 1 8 2-Family,Sq.Ff.� S _ s LOCAUTY a, fi e �menl. �{ Multi-fpmily Sq.Ft. NFARESi 4/y Residenlio�Swimming Poois CROSS ST, � . Date Applicont � OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outkts:Ret_light_Sw._ � ODRE55 i � . COMPENSATION INSURANCE First 10 (ihia s�cfion n��d not b�cempbT�d if}h�work Involwd by 7mol No. CISY Tei.No. � eh�p�rmit 7�for en�hundnd dollors{f100J er In�.) Addirional !� I certify Iho�in Ihe performo�ce of fhe work for which this . qppN�MN permit is issued,I shoil nol employ ony person in any monner so as fo bewme subjetf fa Ihe Wo�kers'Compensa�ion Laws. Li9hling Fialures firsf 40 ADDRE55 � iotal No. Addi�ionat CITY ' ' Tel.No. ' �� °PP11CO^� Fixed Applionces Nof Over 1 HP VERMIi � NUfICE TO APPIICANT; N, after making Ihis Cerlificote of APPUCANt l � Exemption, you shouid 6etome sub(ecl fo rhe Workers' Ronge_Hemer_D.W._ Compr.nsalion provisions of Ihe Labor Code,yov musi forth- Oven_Dryer _W.M._ ADDRE55 �0� iih mmply with.such provisions or this permi�shall be Top _FAU —W.M.--- CITYC iel.No. deemed revoked. � Nood _fan _Othar_ - UCENSED CONTRACTORS DECLARA7ION pCENSE � 1 I hereby affirm thot I om licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.nIUMeER ��j ClossC } � (commencing wiih Section 7000)of Division 3 of Ihe Businen OISTRICT NO. PROCESSED BY O..' Power qpporotus 8 large Applionces and Piofessions Code, my license is in full force and effect. ' � U 7'�1 �v �C Size 8 Type HP,KW,KVA,or KVAR License Num6er �4� Lia Closs`' u Up to 1 Incl. F�NA� � � �����p Over 1 to 10 Ind. DATE ��. ¢' ��l V LIDATION F—� Conttotlor��IC��� .Date-��L--[� Over 10 fo SO lncl. FINAL ,,�'` W � ❑ I am exempf under Sec. Over 50 to 100 Inc. BY ,�y� � �� Over 100 �� � � B.BP.C.for this reason - Z Da�e: Services,Swbd..MCC&Panelboords - � � 0-700 Amp.Under 600 V , . Signa�ure 201-IOQG Amp.Under 600 V � � � ^ � Over 1000 Amp.o�Over 600 V �Exemption for Reg.Maint Elect. � r SINGLE FAMILY Temp.Power Pole&Apportenonces � � � HOME OWNER�BUIL�ER DEQARATION Sign with One Bronch Circuir ' `�� 2 9'�1 R 1 hereby offirm�hot i om e.emp�irom�he Connacior's license Additionol 51gn Branch Circuits� �, s � .�^ Low for ihe following�eoson�Seclion 7031.5,Business and � �}° C � Professions CodeJ: , . ❑ I,as owner of the property,wifl do ihe work and the Misc Conduits 8 Condociors '. � ^�6 6,8 6 struclure is not intended or offered for sale(Settion O1her(See Complete Fee Sthedole)_ , � � e o o(��Qv(�� 7044,Business ond Professions Code). . CONSTRUCTION LENDING AGENCY . ' - O B.P S'�8 6 I hereby a#firm thot there is a construclion lending ogency for � , �he perlormonte of�he work for which this permlt is issued pERM1T FEE (Su6-Tolal) � • (Sec.3097,Civ.C.). � ' � PLAN CHECKING FEE - ' . lender's Name O � PERMIT ISSllING FEE � � � � tender's Address . � i certify thm I hove reod�his oppilcorion ond s+ate�hot ihe TOTAL FEE . �i , obove inFormotion is correct.I agree to tomply wilh oll County ', ordinances and S�ate laws reguloting Elecfricol wiring,and � � hereby outhorize representatives o1 Ihis County to enter upon � ' '� . ihhe above�meNioned property for inspecrion pu poses � �� �„�� �A � � SEE REVERSB fOR EXPIANATORY LANGUAGE �, (h.�Q � Signature of Perminee Oale � �, ' � � . . i. . ... � .. .i. . . . . v . . . ., t „e . ....:•[. r ... ' �' . . . . . ., . . .. . . .. � .. . . . . .. ... �� . . _ (..�-:�.. �.-.:f• �^y:,_ . .. . .. . .. . ' ' 1 _., . .. _�" '" _' '.. . . . ...... ....... . .. . �. � . . � �t}".p�-- ,._� QyYNER-6UILDER DECCiP.RqTION ��.. - ; , � .. -1 �'�AP7GOVACS ' DATF StC'NA'UR � • . .._-- _ \. . . . - ..�.�: \t�,. — - _._ — - � I �.�- , i M:,IPOWER,FG:E - — � � � � �h roby a{f7m iFar 1 om exempt from thd CoM C��'a �. ��. ._�.:`—• `-. � � �'_.� ' ..�f ' �,� ' '_� .; . .- . � Lmensc La •for fho.foliowina recson (Seellon 703i,5. ,- � �- , . . .--:-- UNGERSLA3V�ORK- -��-�, , "� j. -� � � , . .. ,. . . - � 6�sfnessandProfesslortsCodeJ:Anycftynrco�rywfi��fi ' _._._..._ ______.—_ ROUGht COftQUiT. . ..�.-_ .. : ' .'"__.__' :... ... .. ... .. . .: . .:�'e�3ufres h,p.rmii t'"conitrurf,af�cr.imp'rove. of�+olrh. " ----- -•'_- �. _ � � . .,,SLd � � �. ..------ �-� -� N/1RInG 't ` " n,3 2"�r ; Q�{/� Y .,,quiro�ltiaappl7mn!(oraucBpermit'IaBle.Ig�edsta•e� ` , ' .. �. . .. ___ . _ ._. . , �- ' ` FiXiURES � --` ' �� ' :. -ment t5a�he fs dcensed pursvant te the provtsto c of ihc !�� ,-.. �, � �� --` --- -�� '' � � � �Contractor's[fcensa low(Chop�ar 9;(commencing wf(h , . q', �.� . .-. �� ..'POIVERAU7HbR1ZED'�-. '- �---.;. �-.—__._- ', . • ..: .. .-.'... :�:: ' Section 7�00).ofplvislon 3�ef the 6uslnesi dnd Pro(es- �� ` � � � ,tor^fF,00 Qit cr}hot be is exempf}�rmfram and i6e basis UTIUN CO.NOTIPIED -� , ;� � - ,,., 1ogod,exemption,;Any vlolorion�of Sad�on . ... ._ . . _.. ..-'_. — � FINAL 'P ---.... : -____. ..,, �...:,a- ,. . -.,. - . .-703L5 6y cny cpp(i:ant.for o permlt subjocts the oppU- ' _ _ .__. _.__'._.__ ... __.._._____..Gnfcr on��roref � i ,.,�,.' ,, , cant fo a t;v11 penalty.o!nof moro lhart livo hun�ked � � �� NOTES ' � , . �. .. - , . ..-. .-.�� ' dollors(5500).. - . �. . .. . . _._ . . _ ... . � .. ...'. . . .. ... - . .. - .t:.. - �. . � . . -. , , . '. ..❑1 a owner.o4 thc propc�ry wifl do the wo k;�nd � ,-�� � ,:�1he strutluro is nrn fntondad or oHaod for sole. �� . ' ��.�. ... .�- . .; '� I i ;. '__ � ..__ .._.. . �.f5et.�T04�.8osinossandPro�osslonsCoJe� TheConfroo- ��`�'� ' �`1�• �, - � � ��� 4or's llcr�n:c Low docs not app(y fo pn owne�ol properfy , �� `. �,'t�._:r. �� �. :': a \'.`•.. . ��. , , : . ...... ..__. �. ,. � who builds or'Improvoa lharcan, and w6o�does such work htmsoU provfdnd fhaf iuth�fmprovemenis are no� , .�. , ..:.:....___ . .. : �..._-•.'�� ..�._.'........ _ _.__.__...:,_____..._._. -. _ .. ... . . __. ... , . ferr-dforsola��ILhoweve.,fhebutlding'or iMendad or of � -�- �� � � �� � � ��improvemen�is sold wifhfn one yeo.of compfefion:'fFio � � I � _� .. ' �; �, ; � � � ' � � �� owaw•bui(drrwil!hav.}hc 6crdc,n of provinp fhcl he did . . �._ . i . . . `n�'�6vlld or(mprove for 1(�0�orposcof safo.)., '. -�. ' �.. 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