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HomeMy WebLinkAbout1279A (6) WORKERS'COMPENSATION DECLARATION 76A663 �o�a� APPLICATION -FOR ELECTRICAL PERMIT� � I hereby affirm that I have o certificate oi consent to self CE�ee6G � insure,or a certificote of Workers'Compensation Insurance, COUNTY OF LOS ANGELES � BUILDING AND SAfETY ' or a certif' copy thereof�Sec.3800,La6.C� P❑o�icy N ompony �� FOR APPIICANT TO fttl IN . JOB � Certified copy is hereby(urnished. New Residential Bld9s.8� EACH NO. FEE A�DRE55 � Cerliiied copy is liled with fhe coonty 6uilding inspec• 1&2-Family,Sq.Ft. s = S IOCAtITY NEAREST �«'m. tio po m nt. Multi-fomilySq.F. CROS557. �������� Residen�ial Swimming Pools OwNER OR �ate Applicant FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Outlels:Rec_LigM_Sw._ �"�'�� � �COMPENSATION INSURANCE First 20 A�DaE55 + , (Thls f�ctioa ns�d no}b�compl�}�d if the work Involwd by Tolol No. Addifional CITY � '��� Tel,No. fh�p�rmit is for on�hundr�d dollon(SI00)or I�n.) PIAN CMECK 1 cerrify that in the performance of ihe wo�k for which this � APPLiCnM permil is Issued,1 shall nol employ any person in ony manner so os to become su6ject fo the Workeri Compensafion Laws. L�9hting Fixtures First 20� ADDRE55 To�al Na. Addilionol �� CITY Tel.No. f epplicant Fixed Applionces Not Over 1 HP PERMIT f ! N..iICE_TO APPLICANT: If, ofler making this Certificate of AVPLICANT C C� � Exemption, you should become su6jetf to Ihe Workeri Ronge_Heater�O.W._ • Compensation provisions of the Labor Code,you must forth- Oven _Dryer _W.M.— ADDRES ,�� // with comply with such provisians or this permit shall be Top _FAU —W.H.— deemed revoked. CITY �(/� Tel.IV � LICENSED CONTRACTORS DECLARATION Hood _Fan _Olher_ UCENSE OR /r 1 herehy offirm�hai I am licensed under provisions oiChapter9 �isp. _Room Air Cond. — REG.NUMBER Class�, � (commencing with SeUion 7000)of Division 3 of the Buvness DISTRIR NO. PROCESSED BY . d and Professions Code,and my I�cense is in full force and effecr. Power Apporatus&Large Applioncm p q,n � n,�>r Size 8 Type HP,KW,KVA,or KVAR ��a � � License Num6er ���� Lia Class�•� �V Up to 1 Incl. �y� g .Over 1 to 10 Ind. DATE� �j�/�/$� VAIIDATION U Con7rocto���'✓�--L� Dote�� Over101o501nt1. FINAL {.0 ❑ I am exempt under Sec. Over 50 to 100 Inc. BY - fl.' Over 100 N � B.BP.C.for this�eoson � Z Dofe: Services,Sw6d.,MCC 8 Panalboards � 0-200 Amp.Under 600 V SignaWre 201-1000 Amp.Under 60p V ❑ Over 1000 Amp.or Over 600 V_ . Exemption for Reg.Main1,Elec1. � �,� SINGIE FAMILY Temp.Power Pole 8 Appurtenantes � � HOME OWNER-BUILDER DECLARATION Sign with One 8ranch Cirtuit `�''� 2 7�9 A �. I hereby affirm thor I am exempr from rhe Controctor's license Add��ional Sign Brpnch Circuih � �, low for the lollowing reason(Section 7031.5, Business and $i.� e Y •� Professions Code): . ❑ I,as owner of Ihe property,will do�he work ond Ihe Misc.Conduits 8 Condutfors J e�<6 3 0 6 � struuure is not in�ended or affered for sale(Section Other(See Complefe Fee Schedule)_ 2 70d4,Business and Vroiessions Code). � • •�6 3.0 6 c� , CONSTRUCTION LEN�ING AGENCY D E;.P E1"S 6 I here6y affirm thot�here is a cons7ruction lending ogancy for ' the perfarmonce of�he work for which this permil Is issued pERMiT FEE (Su6-Total) �� - � ' � (Sec.3097,Civ.C.). � � PLAN CHECKING FEE � � Lender's Nome �7 PERMIT ISSUING FEE � � �(/ Lender's Address I cerlify that I bave read this applitation and stale ihot 1he TOTAL FEE . above inlormation is rorrect.I agree to comply with oll County .. � ordinonces and S�ate laws regulating Elecfrical wiring,and _ . � hereby authorize representotives of Ihis County to eNer upon th bo�e-rrienrone�,�for i�spection�pO� SEE REVERSE FOR EXPLANATORY LANGUAGE /c bL� � Signoture of Perminee pate , ..... .. . .. .. . .. ... ,., : - ... � ,�.,.:,.. � „ � i.� . _ . . ,. , , . � . ... . , ,. i,� . �. - t ^ ' �,. � ;'-'.. .. � • �.. . . '�', • °..'� . . :.a.. . � _:�. . _,. ._ . i. , .. .. �. i . . , '� , .. . .. .. .,�.. , ..,, t7. -.�-,...�,,� ' � _�..r,, „� .. , . _ _ , „ . • � .. ., .. . . ... C _.. .._ ..� .. . � ; .. ..�-_ ... .-. . . _ , ....... »_. _._�. ,� _��� . ,�'�. `r'qp'Rpr'ALS ��.___DATE_ arc. R __; .. . . ..._ . _. ...... -O /t`7cR-BUILDEP,�DECtAR,4TION��3 � �, � --.SfGNATURF - .-___ . . _-_. _. �•,�. � � ._. �. \ L •..�• ."'.'--.TEMP..POVlEF'FO:E. . -.... . - - �,. . .. . . 1 horeby o?f rm hc' am oxcmp(from�he Con roc•cr's ' _... .'.. :. ,� .i. i i I t .. . , .: 1 _ __ . .`.l_�..'�.. I ... . . . Licenso Lox�.for Iho�4oilowing reoaon (Sect7on 7J31,5, .. . . � . ., . . . . � • ..,'� . '.. � .. ��-��� ��' " � UNDfR5IA9 WORK � � �� � � � . , ' _ ,. _.t 9 � ,. .. ' ' Business and Profess�ons CedzJ�Any dty ar caunfy which � ..�...._...-' ---� -�'�--�- �OJGHCO\OUIT".. - .. � � ' � � . . � ..� .��� .' • �e V(res,oFq��lidtomfrvct,olfer laiprdvc�demoli;h. __._ r 5 �, � �� � -"�- '�-'--- �-r����'cr�repo�ran slrudure;'prlor�io-i�s'iisuance„�alsoro� ��---- � - ---- - V!I'nING-� �•-� � - - � �$� �'fe� � � . qufresfhaapfil:cantforsuchpermHfofifeosfgnodsfate� ' , • � t':. .. �.. ��� GIXiURES - ' ,, " ; . , .�.�.: .--..�� � :. . � ';- mentfhnthefa/feenzedpursuanl}eY6eprovfslon:ofthe .___ „_::� .. ...,._.____ . . ,.,,, � .,.. _ , . .., .. .•. . __. ._...__ . _._ .._ . . .. �.. .CoNra�tor'a Licen.v Law Chap�e�.9'(commencln wlfh "��` ..'., �� .�-� FOWER'A�THORITE�J _ . .._...�_ ____'. _ .. .._._ ��' �.''�'. � ..-� --` 000)�.o Olvlsion��cf�he.6uslness tlnd Proles� . . _.._ . _ . ._ i Sec�ian 7 f. } __„__ _ ... __.__ UTlllry CO.NOTI"rIED___: � � � � � - siorts Codo)crJhal ho Is oxemp�there/rom and tne Sasis t „ _.. . . _ �.for Ihe pffegod eaemplfan. Any v1olo�ion�o/Soction � '���"��' � '���' ��-703. y cny epplicanf�fo/o permit�sub�ecn�hc oppl�� ' FINAL '.L' �� . _.�.._.. .---—.'� ���:� .��t � . . , 1 5 6 i ...._ .-___ . _ _.._ . ____ n.cr ort� rartf� . . �. .�. . • . , .. can}to a cJvil penalfy of nof more fhan llvo hun�ed _ , , � __ d�tro� ssoo�.: __ _. n,o7es :, ! � �.; ;... - ! - _ ' �� _ � � . � I,as owner oi tho property will do the work;-,.,�A - . -�the s�ruauro is nm in'ended or affc�ed for sole.� , �..'\•.. . . � ` . �_�'��. ..��..�', I . (Soe C'044,Q Lrinosds and Pro(osf i�ns Co1e... ih�Cnnfro� . ` �`�;'.�_ ' � - , ._. ; .'.� ._. �_ <'�_. :�.:: � . � � ! � .. 'for's tenro ow oes no app y o an owrtor p proper y . _._ . _ . • . . _ . . : , ._ �,�•.`- -"' � � .�. " t�;�„� ' -� ; ! �� - .,,-. ,,,.: , .,, . who 6u!!ds or'Irnprovvs fhemon, and who�does'sucb � � - � � ' � ` � - � work hfmsell provtdad fha/sut6�lmprovements ara nol : �:��� J „- r. i . •.,\ ..� �._., - -......`--'�'-�'-'-"----"-i �-" � �. . ._�._ . . � 'inlendod ar offervd fcr sale.If.however.the bWfding or . .. ___. .�. _:. .. ..._._.�., , . , I � ' -� �dmpro�emen!is sold wi/Aln onc yeor of compie�ion,'16e � �, . � , � � ' � ��ownorbulldrrwqf have the bcrden af provin,q ihai he did ��,� � - ' - � i � . . .•:.r `:. - . '`:nat$u71d or Improve(ar Yn�FuFPesn b/sale.) . . , �..:,,„ .. .. �.:.�, ' I_.... ' _._ _ �__ � _ ..: ---.. -- ----- _ ,. , �. , '��`t prp•er.empt under Soc._ . _._._... . , � � . _ _ . _ _ _ ,-�__ — j ___._ ": �_ :� . - -- _.. _ _ � . ':.,. .___�. " .- ' ._ B E P.C..for.�his rooson �� . ,-.... . � : � .. .._. .., ; . . ._ _...i- -�� _�: ..'.��..�.'� `— i . . . � . � . .... . � .. , .. , . .. .. : � ,� ; � ' , i . � ,., , � �. ._._ ._ . __ ..._. . `, „ ..._..._ ... __ . _ ._. . ..... ___._. _-____. .... . _ , � . ., . .-.,i�, .:.,, .,�.,. . ...__Date -.._ . i�- -'. --- � �------ ,.�... � -- - - �- .. , __. _ ... . � I � Owner . .. " � �.. . .... � . i � , , � . � _ _ ._ _�. _...__....._. . ,. . - , , ;, .. . . ,: , . ., . `--- , . .. . . .. .. . . . , .`..,_ . ;. ..._...---.-�•-.'- i : : � . - . ..�.... ,:,,�.� ,. - _I__ _i , , ,. � _ _ ----�-- • _. � i '' i - , � — ---- - - - - - -._._.:_ ._.__....__.._ .. ___ i _ ,.'. - .,_..._... . . , , . , ,. �--. .:� --- ---_-___.._ . ----. ._ . . ._ .` _`... t �--_— .._. ..._._ -'- . . . „ . . .. _..._. .......... .. .. .__._._... . i� _\`\ _.... � '�.•,. ..' r-? ,,� .