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HomeMy WebLinkAbout1287A (6) . . _ . . . . � ', .. . . I _ WORKERS'COMPENSAiION DECLARATION 76A663 ,o%a� APPLICATION FOR ELECTRICAL PERMIT � I hereby oilirm that I hove a cerii(imle of consenf fo self CE-Bo6G �nsure,or o ce�tHicote af workers'Compensation Insv�ance, COUNTY OF LOS ANGELES I BUILDING AND SAFETY or a certlfi copy thereof($ec.3800,Lab.C.) � . P❑ollcy N C mpony �/N� FOR A►PIICANT TO F�EACH NO• FEE DDRESS � Certified topy is hereby furnished. New Residentiol Bldgs.&P � /~� � Cerllfled copy is illed with the cou�ty building inspec- �8 2-Family,Sq.Ft.� b� —' f ��CALITY tion ep rtment. /y��' /j� Mulli•family Sq.FI. — NEAREST� _4�� �i�//'YXY C�G[.Kiy Residential Swimming Pools CRO55 57. Da�e Appli�onf OWNER OR FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_lighl_Sw._ ��� �( COMPENSATION INSURANCE AODttE55 . first 20 (Thla s�cfien nNd not b�compl�frd il th�work Inrolv�d by Tolol No. Addi�ional CITY .(C Tel.No. � tM p�rmN i�fe�ona buedrod dollars(SI00)or los.) ' ' I ceriify tha�in ihe performonce of the work for which this A vNCCnHrETK permil is issued,I sholl nol employ ony person in any manner �. so as lo becoma subjeU to the Workers'Compensation laws. ��9Ming Fix�ures Firsl 20 ADDRE55 Totol No. Addilional � �r�-. CITV '. Tel.No. � APP���a^� Fixed Appliances No1 Over 1 HP VERMiT �vvilCE TO APPLICANT: If, ofter making Ihis Cerlificote of � h � Exempiion, you should become subject to Ihe Workers' Range_Heater_D.W._ APPtiCANT Compensa�ion provisions of Ihe Labor Code,you musl for�h- Oven _Dryer _W.M._ ADORESS � �2 i1h compiy with such provisions or this permit shall be Top —FAU �W.H.— deemed revoked. CITY �vJ Tel.No. Hood _Fan _Other_ UCENSED CONTRACTORS DECLARATION uCEN Disp. _Room Air Cond. — 2EG.NUhneER �� Class � I here6y affi�m lhat I om licensed onder provisions oi Chopter 9 } (commencing with Senion 7000)of Division 3 of ihe Business power Apparofus 8 Large Applionces DISTRICE NO. / PROC SSED BY O and Professions Code pnd my license is in full force and effett. , �v V �j//��,y�p.7 �/� Size 8 Type HP,KW,KVA,ar KVAR � � y'ry(/V O—' License Number�lfc.ClossS.� Up to 1 Incl. FWAL �. � /"�i....r iY���/ i Over 1 to 10 Ind. DATE q ��, � Contmcto,aaCG//�- �f�.�Dote�� �I' VALIDATION V , ❑ Over 10 to 50 IncL FINAL W I am eaempt onder Sea Over 50�0 100 Inc. BY � � 8.8P.C.for this reason Over 100 Z � Dote: Services,Swbd.,MCC 8 Panelboards� , '. . . 0-200 Amp.Under 600 V ' Signoture 20I-1000 Amp.Under 600 V � ❑ Ove�1000 Amp,Or Over 60D V r� 2�7 A , Exempfion for Reg.Maint.Elect. � SINGLE fAMILY Temp.Power Pole 8 Apportanances � � � �o e'.• e i'� HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � I hereby oifirm tha�I am exemp�from ihe Comractar's License Additional Sign Bronch Cir[uits � � � ��7�'�2 � Law for the following reason(Setfion 7031.5, Business and � � Professions Code): � •c a"�f j,d`Z� ❑ I,os owner o(ihe property,will do the work and the Misa Conduits 8 Conductors �. ' sfructure is noi inlended or offe�ed for sale(Sectian Other(See Complere Fee Sched�le)_ ► . O F�z S"$b 7044,Business and Professions Code). �, ' CONSTRUCTION LENDING AGENCY � I here6y affirm that there is a conslruction lending ogency for ihe pertormance oi�he work for which Ihis permit is issued PERMIT FEE � . (Sub•Tolol) �, � ' (Sec.3097,Civ.C.). � PLAN CHECKING FEE - � ' ' '� Lender's Name 9] '� �. PERMIT ISSUING FEE � ' �� lende�'s Address �, �',^^ , I certily Ihot I hove�ead th�s opplication and state�hat�he TOTAL FEE . � (j/�C ' , obove informauon is correct.I agree to comply with oll Covnty '' . `�+�..ordina,nces•and Sto1e lawi regulaling Eleclrical wiring,ond ' � '� � hereby authorize represen�a�ives of this Couniy lo enle��pon e obove mentioned properfy for inspeclion pose. � � ��C� �/o SEE REVERSE FOR EXPLANATORY LANGUAGE d � SignoNre af Permitlee Oafe '� ', L,.« .. .' " .. .. .... _, . . . � . . . .� . , r � . ._ �.-�. � .. . . , .. � . ., , , �. . � . .. �:..�. - ...�_., , .. . . � . .. .. . . ,. � . ' ,i. . , . .. .... .�: ..:. . . , . .. !'..,, :_��� . � ._ .. . . i .: . _ .. .. -_ . ,hp7RovA�S nti�-�'" -:_ ... .. __-_ - -�_✓� �QN\NER 9UILDER`D'cCLqP,A ION� . � T I. . . . . � ,�'�' . :, _ .. .. --_ _ SIGNATURF - � � ` y J TF�dP.�FOWEF f'b�E, (� � � -I I horeby effirm ihor�I qm oxompt from the Controcfe.'s . . � .. �.\ .:` . . . - . . , .: `�_;,. . ..�-, ' ..,.._. :_t.\. � . . , : � � . Litonsa :aw for.tha iollawing.rea:on (Socfion 703I�5. �-- _ .�� - . '� �� � UNOEP,SIAB WO�X• � I , . , � � , Loslness ertd Profess7ons Gode)�Any Nty ar counly wh7ch '. ., - ___ . ._ .� . . . ,. _ --------� ---��-- -- P,pUGH CONDUlT -- � - �� ��� - ' - �� � . •.���reqalrp¢a permit)o construcl,aber,Improve�demolish. �� ------_,. -` ----' � . � .� . � � - � ' cr ropnii ony sYrudure,-prfor to Ifs 7ssudpce,�also re- .-�-' -. -- . - ..--- . WIRING.',���:'� - - - �0 ]'��G. `�� ' ... : qvir oapplk chporm aslgne � �'•.- " � —f � "' --�--� -- - .V menf fhat F.o Is flconsed pursuanf�o'tho provlsfom of Ihe r_.-_ _ .. .____._._".� FI,YTUR'c5-`�..=-.� . ' ' •. ...�.� ' CoNractar�LicensaLav�(Chapfor9(commencingwllh � �� -, ' ..__ _ .__i .__.__-.' . ... � �� `� ' �' ' ' � , '�.�.�,.,, --._--.. . ' � Seciicn 7000 of Dlvfsion J of fhe�Buslnese rnd Proles- ..\.�,- � \ „....-_• "�- P'OYlER'i;iJTHORIZED, �- ��__.... _.. -- -----.`_' � . ) . � sions Coda)or fhol he(s exompl fhere/rom and Ibe basis �� _ _ _ UTIIITY CO.NOTIFIED'� '� ' � ' � ,, ./or�Iho-al:egod axomotion. Any violalian of�Secllon :�---- ---- -- FINA� � r �� - ' �------�- • , •.,.� . " '. . .-�7031:5 by an oppltmnt for a crmlt subjecrs fho appli- .- Gi�lc�-aR �roiii�;--- � • � . �;'� Y P - - - - --�--- -- � - - -- - ., ... _ � cont fo a clvff penalty of naf mora Jhan fivo hun5�ed !� ' � �'� NOT'S '- I , . � _.._--.. ..'� '' , do!lors(SSGO).: ti ..-...... - � ��-- - --� .�- � ' I . ��' ' ��-. .', :: . . ' : -' -- ---- I]I,d:owncr bf tho p�opcity will do ihc wqrk. ..�d ---- -- - - :� . . ... -� ���. ,�.,. ., ,:,, , ._ � i ,. -� '-�� ' �� � � � . ihe struUuro is�not intendad-or offerod for sole. .. � � . �,., . . .t.,. � .. .. ', '� ! �', ___ r. :. . _ , �.�; ' , �,� (Soc..70d4.Cusinessa�dPro(essionsCode: ThnContrac , � ������� _ ' ' � � lor's Licenae Lo•.v dors nof appfy to an ownrr of propoNy « ' .• ,--,�i�� � � '� , � who 6u7fds or�Improvon Iboreon, end who does such ... � � � '" ��'��' ' i � i . --""� �� "'�- � - ' work hlmsalf provldAd�ha�such�lmprovements are no� . .' . . •�.. . . ...�.. �.. .�.,��. �' .. .. ..--i -- � '— --� --- " ", _.. . � 7nfendud ar of(orvd!or sale.dL however.�he 6ullding�or � ,�.. - '.,.•. � „ �.• -- - .��.. .... _,........_ ._.._ .....__ .. .:, _-..._ . . � � � ImprCvomenf Is sold w/fhfn ono yoar o(tomplolion.Iho . . _ � � ' '� , �� � �� � owner�bolldcrvdllhwefhobu'rdertofprovingthafhedid • ' � � ` � � ' " � �not�ulld or Impravo for,ff�c ovrpos9 of sale.) �. \ . , , i .., .. .. � � , � , . ..,. . . .. •�.. � . ., � �, . � i . . , r -� � . .. �,. .. ._ "_ . . - . . , , � � . _... __�__ . 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