HomeMy WebLinkAbout1292AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or rtif copy thereof (Sec. 3600, Lab. C.)
PP16//rNN Company
Certified copy is hereby furnis ed.
Cerci ied copy is filed with the county building inspec-
t' t ent.
Date Applicant��•
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by
the permit Is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject 10 the Workers' Compensation Laws.
Applicant
NutICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and myyJlicense is in full force and effect.
License Number �r���cceQse�Lic. Class
Contractc,4 /9 � s' _& Date
❑ I am exempt under Sec.
B.BP.C_ for this reason
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby offirm that I am exempt from the Contractors License
Law for the fallowing reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lenders Name
Lender's Address
I certify that 1 hove read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lows regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
th above -menti ed propert for inspection puror
oses.
�r�7Yl s
Signature of Permitlee Dote
AW'°'B'
E -1506G APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN JOB/,�/'
New Residential Bldgs. &f(��
EACH NO. FEE ADDRESS 7J
1 8 2 -Family, Sq. Ft. /y/ 5 — E LOCALITY
Multi -faintly Sq. Ft. — NEAREST
T.
Residential Swimming Pools CIOOWNER OR
FIRM NAME
Outlets: Rec_light_Sw._ MAIL
SS
First 20 ADDRE
Total No. Additional CITY,/'WIA14 T.I. I
O
V
t3
W
a
fl7
Z
PLAN CHECK
APPLICANT
Lighting Fixtures First 20
ADDRESS
Additional
Total No.
CITY
Tel. No.
Fixed Appliances Not Over 1 HP
PERMIT
Range_ Heater—D.W. _
APPLICANT
Oven —Dryer _ W.M. _
ADDRESS
Top _ FAU — W.H. —
CITY N
Tel. No
Hood _ Fan _ Other_
Disp. _Room Air Cond.
REGNNUMBER
O
Clas 6
Power Apparatus & Large Appliances
DISTRICT NO.
J
/W,1
PR9FESMD BY
Size 8 Type HP, KW, KVA, or KVAR
Up to 1 Incl.
FINAL
Over 1 to 10 Ind.
DATE %.•I
'y/�
- VALIDATION
Over 10 to 50 Incl.
FINAL
Over 50 to 100 Inc.
BY
Over 100
Services, Swbd., MCC & Ponelboards
,
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
".. 12 9.2 A
Additional Sign Branch Circuits
#:ee..112
Mist. Conduits 9 Conductors
Other (See. Complete Fee Schedule)_
►
I" = 6686
e�•6686'.
0&25-'86
PERMIT FEE (Su6Totol)
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE /
SEE REVERSE FOR EXPLANATORY LANGUAGE
O
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._.SIGNATURE
TEMP.�OVJ,;J7 POLE„. � ••--_ - ._:. - •.. ....
UNDERStAB WORK - _ _ ___
ROUGH CONDUIT
vl)zlNG ` .. o O 1
J'�7 ( i
:lXTURFS '\ .
t'dflERrAllfNrJRi2ED--' - -.--, -- -
UTILITY CO, NOTIFIED
FINAL __. Grirteron•_Yion7-_.__...
i_OyJNSR-BUILDER DEEP F'ATION •,`�
1-'- - - --- I hereby offirm that I'am'exempf from't6eContractor's
, Licersa Law for the -following reason (Section701ITS.
Cus7ness and Professions Code): Any citynr county wh&h
rsqulres aTpo?mil to Sonmtruct, after, fi*4nr ,V Idemofish.
•�' mor
rep.
1, 'prior to Its Issuance,\dlsa re-
quires the applicant for such permit to filo a signed stole.
ment that he is licensed pursuantto the provisions of the
Contractor's License Low (Chapter 9 (commencing with
'-- -- Section 7000) ef,Divlston:J of the Buslness and Profes-
s. slons Code) or that he is exempt therefrom and the basis
,for the allegod axampil-,•Any vlolation of $action
.7037.5 by any applicant, for o permit subjects the appli-
NOTES
can to a c1v11 penalty of not more than five hundred
doflo . _.. -
... " '' r' rs (5500).:
114, as owner of the propertywill ,do the ark, .., ni
` he structure is not intends oro ered for sale . -
� (Sac. 7044.'usiness and Professions Code:. The Controc-
-.. --. -
,1, � - - - � \- _ � - • rs license Law does no apply to an owner of property
wt
who builds or' lmprovecthereon, and who does such
work himself p rovidod that such: Improvements are not
" .. • .. _.. .. _.... - _ , _ .. ". : - -_..i - _ ______: .._- .__. _ _ - -- .yntended or ofe rqd for sale, if, however. she building or
-- improvement Is sold within ono year of completion, the
owner-bu:fdor will have the burdcp of proving that he did
nas bvtld or 7mprave for the-durposao! sola.)
' -• _ Larn•exempt undar Sec,
B & P -C_ for this reason
Owner -