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HomeMy WebLinkAbout1293A WORKERS'COMPENSATION DECLARATION 76A663 ,o-a� APPLICATION �FOR ELECTRICAL PERMIT � I hereby affvm thai I have a cenificate of consent io self �E'e� inso�e,o�a certi4lcate of Wo�ke.s'Compensoron Insurance, COUNTY OP LOS ANGELES BUILDING AND SAFETY or o certifi op thereof(Sec.3800,Lab.C.) P❑o�ity N ompany � fOR AIPIICANTTO flll IN �OB /Jn Cerfified copy is hereby furnishe . New Residentiol B�dgs.8 P EACH NO. � ADDRES /f/ � Certified copy is filed with ihe county building inspec- 1 8 2-Family,Sq.Ft. E = S �OCALITY � NEAREST �`� tio ep Iment. Mulli-fomily Sq.FI, fR055 ST. ��� ��'r� �� Residenlial Swimming Pools OWNER OR Dale ApplicoN � � . FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec�light_Sw._ ��� p COMPENSATION INSURANCE F.S�� ADDRE55 X 7 (Thb s�ctlon n��d not M complN�d(f fh�work involwd by 7otal No. Ct7 Tel.No fh�p�rmtt is For on�hundr�d dol�ars(SI00)or I�tt.) Additional � I cerufy thm in the performance oi ihe work for which this . . pppN�N7K . permit Is issued,I shall not employ any person in any manner '�. so as to 6ecome subject to Ihe Warkers'Compensalion Lows. Lighting Fixtures Firsl 24� ADDRESS Total No. � Addilional �, ePP',Cant , ; CITY Tel.No, Fixed Appliances Not Over I HP . PEeMit t�_.iCE TO APPLICANT; If, after making ihis Certifimte of � � ' APP���M l� �� �/ Exemp�ion, you should bemme subject ro the Workeri Ronge—Healer__D.W._ I Compr.nsation provisions of the Lobor Code,you musl forth- Oven _Dryer _W.M._ ��, ADDRE55 �� /� wifh comply with s�ch provisions or Ihis permit shall be Top _FAU :—W.H.— � CITY Tel.No. deemed revoked. Hood _Fan _O�her� ' - � LICENSED CONTRAQORS DECLARATION . IiCENSE OR r� � I hereby affirm thot I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER �,7 Closs� (commencing with Seclion 7000)of Division 3 of Ihe Business � DISTRICT NO. PROCESSED BY a Power Apparotus 8 Lorge Appliances and Professions Cade,and my license is in full force and effect. O ��jQ�Q'1 /Y Size 8 Type HP,KW,KVA,or KVAR' �, 'P' U - License Number��,C�_Li[.CIasSL /D Up ta 1 Incl. ' FINAL OS �✓f �n� Over 1 to 10 Ind. DATE .I� �'/�f� � VALIDATION � 1-�-" ContrauorC�/�'��'�/rV Uate_� Over 10 ro 50Ind. ❑ FINAL W I om eaempt under Sec. Over 50�0 100 Inc. BY lY��� N� Over 100 �� 8.8P.C.far this reason . Z Date: Servicei,Swbd.,MCC 8 Panetboards , ► 0-200 Amp.Undet 6W V Signature 201-1000 Amp.�Under 600 V � Exempiion for Reg.MoiM.Elec�. Over 1000 Amp.or Over 600 V - � SINGLE FAMILY Temp.Power Pole 8 Appurtenances HOME OWNER•BUILDER DECLARATION Sign wi�h One Branch Circuit - � . 1 hereby affirm iho�I om eaempt from the Controctor's License � Addirional Sign Bronch Circuits � � Law for the iollowing reason(Setlion 7031.5, Bosiness and , Profess�ons CodeJ: �� 2 9,3 A ❑ I,as owner of the propeny,will do the work and the Mrsa Condoi�e&Conductors . . . srructure is not intended or offered for sole(Section Other(See Complete Fee Schedule�_ ► $;�•'" � �• �L �. 704d,Business and Professions CodeJ. � ^ 0 6 d 8 6 � '� CONSTRUCiION LENDING AGENCY . � ! I hereby affirm that the�e is a construction lending agency for � e F, c 6�g 6= i the erfwmonce of the work for which lhis ermit it issoed � � �- � U P P PERMR FEE {Sub-To�al) ' (Sec.so9�,Cc�.C.). 0 8 2 5•-8 b , ' PIAN CHECKING FEE � lender's Name .v� � ' PERMIT�SSUING FEE � � �✓ � lender's Address � � � I certify Iho1 I have reod this opplication and stale that the TOTAL FEE . . . � obove in/orma�ion is correct.I agree to comply with oll Coonry . . �. ordinantes ond State laws regulating Elettricol wiring,and . � , . ' hereb au�horize representot�ves of�his Coonty ro enter opon � '�, . � the ove-mentioned property ior inspeaion pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE " • � 7�?���.P 8��'��',� ' �� Signafure of Permittee Date , � . , , , . . . , . . . . . � . „ . , ; , , . , �,.. . , . . . , � , , . ,. . . . . ., . . .. , . .. . _ . , � � t , .-.. r, . _. .. . � <.�E��..<< C:1�=� 1"7!�,.�.:�� . , .. . , , ..- . ,. . . , . . ...._. . -...: . _. _. � . ....___.__..- N - ILDE - ' . . 5 ei, � ;-:-:. � . �<.01r! 'cR BU R�E�IARATI�N�. _.. , •:�-� . r .. ...' .._� 'APPt!OVN.S . . �..._. ._DATE___.. . _. SIGNATURE _ -.. -_�__..._ _. -. ., ______.� ._ �'��._._ . ' . � - � �'�} .:: . � _ .�.,. � _ .. I ;�- - .- � � __. �. TEMe:70V/EP PO.E, ... . .. .,- :.----, :���� �.�� . . .. . 1 ho•e6y afFirm hat am�exemp�from fhe Cont aq�cr i . ' . . , . ���_ : . , . �..�• , .. .License law for'thol4ollawing,reason Secfion 7J3F.5, • . . _. . .�. , .,� .. � :�..____.. `..�._1•_� - -.. UNG�RSLAB WORK�;".'-: . _ . . ._. , � ' -- . , � , - '� . _ . �� - . ._. ..__ ._ . . t �_.. _. ___-.----- -�-' i'OUGHCO\pUiT..��. �- � ,.,.'�. . �'�.. �'�... ;\,�rc dpeFm!lictonsteru�t,ohnr {'nplpve.'-de oli�h, ` �� ' --' .'--��� � ---�-�--' .. . ra epalr ony.��ocfure p'tor fo�ts/siudrtco a�so rr + , . . . _. � r . , , , .. , , »,,� 1 ------- .. --. ---'WIRII.O`�\ .''--"-': '��S �,r � (l'y�3 � , ,. .., ... . ,. � qul o:f5o applimnf/orsuch perm/f}o fila o slgned slotu� � � '�"``�`�'� - " flX7lJRES '� ' � � ' � ' � men/thc!he(s Lconsed purtucnl fo tbe provlslanc o/Ihe ' . _.. . .__ ___ -.. �_- . �-.. .. : �,._: �. - , � __.._.__ _._:- .._..__.._ .. . . ; �i Cootroctor's!ltense Low(Chapfcr,9(tommenGng wllh . ... _ �'. ,, �,.. , , , . � - � � . . .. .� �. r`...Se[fion�000 � '.� ____...`-� POV:ERAU7FiORRE�'.•-. -._,:_. '__. __._._..___. ",..'. ----- J.oi 0ivlston�3��o1!he Bvsiness and Profes� � �� � - ', ; , . � , . ,slons Cddo)er Ificf bo Is oxempf�herelrom and tne basis _ . UTILIN CO.NOTIFIED-'- �i ; t „ � ior t}.e�clfeg�d Saempfion.�Any No)alion o/Sact�on � ---- _ -.- ' . ._ . - . . ..._ FINAL , '�' ,.n:� . ._..._ ._.___. .. . � ; . ...� '; ^�.� ; ... . bycnybppli:anf/a�.a permftsubjocn�ha appli.. 703 f 5 , . , _.___ .. . .. _ _._ _ ._._. n(c�n ronf � � , . �: mnf fo n clvll penahy of no�moro ihcn llvo hundred '...'__. . .. . . , , . ._._ . . . � � � NOTES . � � . � .. - .�'.� i .._dolfars($SCOJ.___ � . .. . ..._. . -. - . �'= .._.� . � ''. , i . � �' . '�' . . ..... []I,os owncr of rho proPcrty.vill do the wor4, .d . i . - ."�• , � �.''.. �...-:-`- � .�� `'� •". . ��� , �� ..,.. .- �-� � .�..the,arrusture i�nct i��end�d or offc�ed for sole, . .. , � \,\,`,` -. . , , '__. .. ._ , . .. __ . . , � - -..(Svt.i0-f{,Buf)nossandPro/ossionsCode: �iheContrac- � , .. . . . . � .i .. . _n ,� � " -. `. �--• ,-�. - .--� ' .. . � � . ' ior's t(cense Low�does noi apply to an ownar olproper�y � . � � ` � ' '��!�'' ' �� � , who 6u:ld;or�lmproves thoreon, and whe�does such ' . .:' � \._:. ___. � .i ' ; ��.:,� . � ' . , . . . ' � " �" -�-' � � �� wcrk hlmsvi!provldnd t6o1 iucR Impirovements ore nol �.. ,,, .. ., : . `_�. .. ..' . . ._.:_._. __�._...__.._.__._..._, --- . . . .. _.._ ., � , , . infendod oroHerad(or sal3.11,however,ihc bWfdin��or - � ���� � � -� - �� �Improvemenl 1:scld wllhin�onc yeor of compfclion. Iho � � " . ����o'wnrnbulldc��wiflhavethebcrdnqofpravinglhcfhed,'d � ' � � � �� � � - �`no."Evfld or Impro✓e/o�thopurposo ol aalc.) , . ;.. .. �. . ., . . . . . . � . , . . . ..•, , _ .. , . .. 1 � , .�. . i � ��,i.�� __...._ . ..1.,..:. . . _.. . . . . : . . . .'_'_._ ___.,-.._.._ __.___. . __ ..._.._. : � � � � ��i am exenipt�nder Sec� � i'- � , . .; . . .�, . t . � ,. ., J!; .,� � _., .�. . . , .. : . . . ., .a � _- —_ --< � ----- � � ` - ' _.__B E P.C_f❑:.fhis.rooson - �.. . ., �' �: . � .,.... . .. _�._. .,.. _. .._., . ,- . .. .. �� I , . ,,. , :.� . : ;�:�,: - � .: '� � , . . , _..._.__... . . - -- � .. .---- ---.. � .., . . , , , . ..�� .,, _, : . �-Dote . . ._..._.. ._--- ----- . .. . . � . � ._. . -- -- �-- --- - - - � .�- - . . .,..... � .., ,. , . __ _ ,_ � . _.. ,_... : ; , _. �, .,,, . . .. � . .. , , � i � Owncr �. . _ '_. . __--- �-. , „ . � � �....,:. � . .���j �. .. i . . . , � � � . .. .. . . . . . . . . . . � . . .;... . t..�.. ..____'..,._'___.'____' .. ,. . . , . . � .. . . , . � . t�.' �.f�.. � �. 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