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HomeMy WebLinkAbout1291A (6) WORKERS'COMPENSATION DECIARATION 76A663 �a.a� qpp��CAT10N FOR ELECTRICAL PERMIT � � I hereby affirm that I hove a certificale of conseni lo self �EaaSG ins��e,o�o ce�sfico�e of Workers'Compensaron Insu�once, COUNTY OF LOS ANGELES BUILDING AND SAFETY ��eriJ�jf{��d ropy fthereof(Sec.3800,Lab.C.) � �1 .7'��`�/ Company�/N� FON AMLtUNT TO flLl IN �OB �S � Cerrified copy is hereby furnished. New Residentiol Bldgs.&P I EACH NO. FEE ADDRES (/ 0 �Cerlified copy i:filed with the county building inspec• 1 8 T-Fami ly,Sq.FI.� E � E LOCALITY � dep Imen�. Molli-fomily Sq.Ft. NEAREST � � Residentiol Swimming Poals � O�ER pR � Dafe� Applicant G . . FIRM NAME .y , � CERTIFICATE OF EXEMPTION FROM WO Oudets:Rec_Lighi_Sw._ ' - �`�� � COMPENSATION INSURANCE AD�RES This s�ction n��d nof b�cem I�t�d if th•work tnvolv.d b First 40 � P Y Total No. Add���onol CITY Tel.No. , th�pormif b ler oe�hvndnd dollors(f100)or I��s.) PLAN CHECK I certify ihat in the performonce af the wo�k ior which Ihis ' qFVLiGat,lT permit is issued,I sholl not employ any person in any manner � so as ro bemme sv6jec�io the Workers'Compensotion lows. lighfing Fiz�ures First 20 A�ORESS �, To�ol No. Addiiional oPp f`on GITY Tal.No. NvfICE TO APPLICANT: If, after making this Cerufimte of Fixed Appliances Not Over 1 HP ppM��pNT ! y E�empiion, you sho�ld become subject lo the Workeri Ronge_Heater_D.W._ � Compensalion provisions of fhe Labo�Code,you musl forth- O�en _Dryer _W.M._ ADDRE55 /`� � iih comp�y wirh such provisions or this permit shall be 7op _FAU —W.H.— �� � deemed revoked. Hood _Fon _Other� CITY � Tei.No� ' LICENSED CONTRACiORS UECLARATION �ICENSE OR �/Y ' DiSp. _ROom Air COnd. — REG.NUMBER C���;/� � I hereby affirm ihol I om licensed vnder provisions of Chapter 9 }j , (mmmencing with$edion 7000)of Division 3 of Ihe Business . pa,�„er Apporofvs 8 Large Appliances DISTRICT NO. � PROCESSED BY O. and Pro(essions Code,and my license is in full force ond effecr. V Q /y��j� Sixe 8 Type HP,KW,KVA,or KVAR� ' License Number �`� lic.Class�_{� Up l0 1 Incl. FINAL -� , /�/ O �^�''_� Over 1 fo 10 Ind. DATE � � 'b DATION h � ContractoC���Dote�2_!4 "� Over 10�0 50 Ind. W ❑ FINAL a I am exempt under Sec Over SD l0 100 Inc, BY N B.BP.C.for this reason Over 100 � . Z Date: Services,Swbd.,MCC 8 Panelboaids � 0-200 Amp.Under 600 V . Signo�ure 201-1000 Amp.Under 600 V � ❑ Over 1000 Amp,or Over 60p V � � , Exempiion for Reg.Moint.Elecf. � SINGLE FAMILY � Temp.Power Pole 8 Appurtenontes F! � � - � HOME OWNER-BUIIDER DECtARATION `1 2 9•� A Sign with One Branth Circuil I hereby affirm thot I om ezempt from Ihe Contracfor's License qdditional Sign 8ronch Circuits �° �a� '2 Law for the following reason(Senion 7031.5, Business nnd � Professions Code): I < o b u S 6 ❑ I,os owner of�he property,will do ihe work and the Mrsc Conduiis&Conducfors - , structure is not imended or offered to�wle(Section ��her(See.Complere Fee Schedule)_ , � �< o o(,,(��b� 7044,Business and Professions Code). �, CONSiRUCTION LENDING AGENCY 0 8�'6—8 6 �� I hereby affirm 7hat ihere is o constroclion lending agenty for . '. the performance of the work for which this permii is issued pERMIT FEE � (Sob-Tdal) � (Sea 3097,Civ.C.1. . � . PLAN CHECKING FEE _ � � � , � Lender's Name /D � PERMIT ISSUING FEE - � lender's Address � I certl(y Ihat I hove read this opplfmrion and state Iha�the TOTAL PEE � � - above inlormalion is correct.I agree to comply wuh oll Cov��y � , ordinantes and Sfare lows regvla�ing Electrical w�rin9,and - hereby outhorize representatives of this Counry to eMer upon Ihe ove-menrion,�rty f�ctio rp6se� . - `� �, SEE REVERSE FOR EXPLANATORY LANGUAGE O/ Signalure ef Permiltee �ale ... , ,. , , R:. . .. . . _ .. .. , . . ; .. , ,r. . , .. . _._ . . . ' . ,..� � .-�� < . "'• ..� :aFFR4vj�15 :.. DA7E a_ K a `.; ._._.. .. ..____..._.._ .. ..OV.�NER-CiUILDER DECL4RA710N ,< ,. .• ! � �,. . . _ __ ..SIGNATi1R -. _ _. .. ..__.... _. __ �'.� ' .., . . . ._ .. .. . . . .. i .� -- -� �I.TE1�1P.POWER�PJIE,. - - � � �� • � I hereby�ffirm ihar I-am esempf from the Contrcclor's .t �� - - - � - ._._ . ._ , , ,..- � . . . . . Licensa low for the.following rea;on (Setnon 7031;5, � � -: �- .,;,._\. UNOERSLA91'vGRK��- . � _ ` , � , C.ustness ond Frolosslons CoJe):Any ciry�.nr co�rny whith ` � � � .�, ��, �.. .. , roqWrns e perorlf to construcf,aher,Lnoio've;dumolish, , .._ . .____. _ ROUGH CC'VDU'"�r .' � �. . _. . . . . �. .__ ..._ ..__.__ . .-- . -.- -� WIRING` --' 'j �' �' � � " '��quGeslhooppilrnn}I/arsuchpermtf/fotlloaslgnedsfa�e- _.. � . . � ��� C � - ._ _�_ ,.- ._ '. :_ ___ � �... � : � .� �� mont ffiot hv ir Itcemed pursuan�fo the proWs�ons of fhe ' � _... `_._..'F(XTUFES' .. _\ �� ��. t . ,.. - ., .. . - ����. - .. ��-_'. ._ ... �.._..__._: '". ' . ,..�,�Conlractori,Utrnse Lwr.(Chaploa9(mmmenNng with �.�.. '.J.�. �..�� FOWER AUTHOFITE���. - -'--=-._..__. . .__..__"_' '.: ' � '. ��---- '�-:..-`:.. ' ' ��Secflon 7000)of Divlston.3 oi fhe 6usfnese end Grofes- ;.��..` _ ::��, ..._--- � ; ,,� sions CodeJ ar lhv�fiu ls exempf tFcrefrom ond the 6asis �. UTI!ITY CO.NOTIFIED�'__� _, , i� '; i _!cr tho�p!(ogsd exomptlon.�Any vlola�ion o! Secnon �.. . . .�...- ... ... FINAL , ' ._. .�_ �._-.---- '_'_ '...�i :� .:.. : . . .5 6y any oppUconi(or o permit aubjects thn oppli. - nc� i 7031 ' ....__.__ ,. _ ._..GixLer oR..droieL� �� :...,�,. . � conf}o o eW(I pena(fy of nof more ffion Vive huncked ..__. . .'___ � � �� NOTES ; � �' � '--�"� -�"- � � dol/ars(SSGO): � � ' ,_... .___ ...... _._ __. . , . _ . .. . ,. . . . ` ._...y � _ .��.,�• � �'i ; i � ,.. ...'� -' . � . . , ` . �❑I,as owner c4 tho areperty wd�do the work:..nd � .the struduro is na�in!ende or ofieiad for sale. � �1��\ . . .. � .' � . - - . . ._._. , , .._- •.,, ' ..�(Sec.7644.�usincsa and Proless�ons Code: 7he Contrac� . ' �'' ' ����'-� -��� �'---- �-�- � �� �� � I ����- foritfcvnsolowdaosnoiappfytoonownerolproporly -�.;.".. ,�,��_ - `� " •, ��y '� �.�'�.':�, ,'" -. � ' - � „ who 6uflds or�Improvm ihoroon, and who�does such ' � �- � � � � `� work F.tmself provl8od Ificf such�improJzments are no� � `.-,\ � , .. ��.� '�.' .-,. . .�..: -�-- ----';.- ,...-�---�� '.._ . . . '.... `- .. .. � ..�7rtfenood ar offorod for sale.1!.�however,the 6vlldine�'or . ..._ .....___._,.__... . . ___ ... . . . . , j ' � �rymprcveir.ent ls sbld w7lhln ono yed�of complefion,fbo . . _ . I �� - ' - - � �owner-bWlderwllf I:ave tho burdon of proving lhot he did � � ' � ` �not bu1Jd cr tmprove Ior ebe durpos�.cf sale.) , � " � � . . , � -. ,, . : , �, . .� � , , . . . �. ,..,. --" .. . . � t , . __. .__�..'--._--- ,. . ---- � . .. . �, . ��` , -.. ., .....� .. ,.. , .. �.I am�axempt�undor Soc. . . . � �. . _.. --- , - � . _ . . , - • . .. _ �- ;, ---.. _.__.._._ , --• ' _.'.. .�....: .. :.�:' . _..__..._-- - . ._.__._._... � .. ____. . . _.. -, ._� - .. �. ��: � ••�.�-,. ,. �. ,...�, -, . -.'' -...._. .... ._J , .. : i �... ��,. . � , . ...._ �..... . _._ ._ _,. __ ___� . . .. . _._B&.P.C.far_fhis rea..on -�.,,.'.. ' .. . . �---..'�� ._..._ .�� .:�.__.---._. . .�..--- �=---- ---. i�.��� .. : ' . ,_-- � , �.�-.., _a , � . ..�--. , .... ____._ . . � : � �-,, : ,. .. . Date �---. _ . ._�- , ---�--i , . . � , �. � Owner , � �, .. . , � �. . �- .. . i , � : ,_. . . , , ..,,.,. ,..� � . .___. _........ .........___.� . .. . . .. � . . .. , � �. i� . . ,., �. , � . � . . . �, . .. . , ,__. . . . _._..-'---... ... .__.--�--., . ... . ' .. . . . -, . , ��-- . . .. . , .. . _ . . . . � ,... . . .. .,. . . . . , '' _ ,- - f . . , , . � � . , , . .. .. . . . . .-:-:� _•:- --- �- ---.._.__...__.._.__---. . . �. ' -- � � " � , . , . .. . .... �� � .-__ . _-- ---_-_ ._ _._.__ ... .. �- .. -, . . � . ..._ .... . . . .. .. .. ... .. . _.. ._ . .__ � ., � .. -t.��� �'i _l •�J