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HomeMy WebLinkAbout1660A (9) WORKERS'COMPENSATION DECLARATION �aA� ,o�e, qpp��CAT10N FOR ELECTRICAL PERMIT - � I hereby affirm �hot I have a certificaie of ronsent to self �E'8�' , insure,or a certifimte of Workers'Compensoiion Insurance, COUNTY OF LOS ANGELES ��B ILDING A1�D$AfETY or a certified copy�hereof(Sec.3800,Lob.G) C � ry� � PolicyN �CJmpany /NOUS�U�L _ FORMYl1GNTTOF0.LIN !OB ; / � �,�,/Cerfified copy is hereby furnished. �I'-�� New Residentiol 81dgs.8 Pools EACH NO. FEE A�DRESS I 1Y Cerilfied copy is filed with the county building inspec- 1 8 2-Family,Sq.Ft. f = E ��CA��TY +� ''s� de rfinent. Mulli-fomily Sq.FI. NEAREST �. Da{e�� �7 Applican 1�� Residen�ial Swimmin9 Pools OwNER OR FIRM NAME N CERTIFICATE OF EXEMP7ION FROM WORKERS' nnnit / Outlets:Rec_Light_Sw._ � � COMPENSATION INSURANCE First�0 ADDaE55/Q AJ (Th(s s�dloa n��d not b�complMad ff iho work lnvolv�d by Tolal No. Additional � CITY y���` el.N G�-fi� fM p�rmit b(or on�h�ndr�d deilers(5100)or I�sc.) I certify that in ihe performance of�he work for which this , ' , qppNCAN7K permit is issued,I sholl not employ any person in any monner .. . ' � so as ta 6ecome su6ject l0 1he Wockers'Compensation Lows. liqhlinq Fixtures First 20 ADDRESS � Tolol No. Additional . ❑TY . Tel.No. . Dale Applimnt Fixed Appliances Nol Over 1 HP PERM�T NOTICE TO APPLICANT: If, afler making ihis Cer�iiimte of APPLICANT,f'I� � /L ' Exemption, you should become subjeU to the Workeri Ro^9e—Heater_D.W._ � Compensation provisions of�he Labor Code,you must forlh- Oven _Dryer _W.M.— ADDRE55 �D• X. `��/ with compiy with such provisions or Ihis permit shall be 7op _FAU —W.H:— � deemed revoked. � CITY Tel.N . � LICENSED CONTRACTORS DECLARATION Hood _Fan _Other_ IICENSE OR % I hereby affirm thaf I om licensed unde�provisions of Chapter 9 DiSp. _Room Air Cond. — REG.NUMBER Clos. � (commencing with Section 7000)of Division 3 of the B�siness . DISTRICT NO. PROCESSED BY O_' � Power Apparatvs 8 lorge Appliances ' ond Professions Code,and my license is in full force and e4fect. ' O �1 Size 8 Type FiP,KW,KVA,or KVAR �. I V License Number L � lic,Class �/ FINAL �� � Up 10 1 Incl. �e�J�7!y � �� Over I to 101nc1. DATE 91►L�6y VAUDATION U Con�rac�orC.r_/_7�sJe�-L�Date Over 10�0 50 Incl. ❑ FINAL n W I om e:ampt under Set. Over 50 l0 100 Inc. BY ' ,f.__�� N Over 100 ��W�� B.6P.C.for�his reoson , z Dale: Services,Swbd.,MCC 8 Panelboards ► ' 0-200 Amp.Under 600 V �� � . Signature 201-1000 Amp.Under 600 V �`�•6 b�� . Ove�1000 Amp,or Over 600 V � �� � � I � Ezempfion for Reg.Mairo.Eled. �� f��.�''�e f �. � o •2 rJ.rJ p , SINGIE FAM�IY Temp.�a w i.-0ole 8 Appurtenances � HOME OWNER-BUILDER DECLARATION Sign wi�h One Branch Ci�wit I • • •2�J.J�fx�c=i 1 here6y affirm thot I om exempt from Ihe CoNractor's License Additional Sign 8ranch Circuih- � ', � �g,� FJ—8 f Law for�he following reason(Sec�ion 7031.5,Business ond � Professions Code): ��. � � ❑ I,as owncr of ihe property,will do the work ond the Misa Conduils 8 Condutfors , , � � shucfure is not iNended or aifered for sale (Section Other(See Complele Fee Schedule)_ , ; - � 7044,Business ond Professions Code). � CONSiRUCTION LENDING AGENCY � � I hereby affirm thot there is a conslruUion lending ogency for �, the performance of the work for which this permit is issued pERMIT FEE � (Sub-Total) � ��, - (Set.3097,Civ.C.�. �. PLAN CHECKING FEE � �, - ', � � - ,. ; lender's Nome � � 7ERMIT ISSUING FEE � �� � ' � � - , Lender's Address '. � � I cerfify 1ha1 I have read this application and s�ate 1ha1 Ihe TOTAL FEE � � �� �� obove informarion is correcr.I a9ree to tomply wi�h all CouNy , ; � ordinances and S�ate laws�egulating Electrical wiring,ond � � , � hereby authori:e represeniaiives of Ihis County to enter vpon .. obove-meNioned pwpe��y for inspeUion purp ses . • � ��_/,-��O� q � SEE REVERSE FOR EXPLANATORY IANGUAGE _ - � ✓� ' Signafure of Permiltee � Date � � . . . . , ..- ... . ... ,.. ..._ � .. , , . . ,, _.�• . , , ., � ; :• � ,. , _ . .. . .. . : . . . : _,. ... . .: . , , ... , . �:.�� � � . ,��: . . . ;. ,._ _, . .__ �- ` . . � -- --_ ... ._. . ._. �•.,. OWNEic-BUIiDER�DECLA,RATlO`J` . . .... . , TEh1P.FOW RVFOLE. �ATE ` �` . _. _ ..._._ "'. _ � . . . , _. , .... ., �. � . . .__._ ___._ SIGNA7URF. �- �:- .' � - � ` � � - ' ' ' "� I he�eby nlfirn thot I'am excmpt from the CantrcUor's , ., . _... _._ __.._ . , .. . , . _'; � . ..."'� �. .�. �� Uti�EFSLAB VJORK��� ..._.. .. _. ______"._"_ -__ ..__.�. ., � .. i _ . . g reoson fSeclion 7037.3, � � ,��.� ' * �. . „License �oH, tor the followir, _ _ :� . _ . , ' Eusine5sondPro`esslonsCode):Anyclfyurcoor�(ywhlch r. .. .___.._.__ .. - -.. ROUGH CONDU!T- .�. ._ ._" _._.�. ",.___"_' :. , ;�..:... . .. ... . roqvirc`a porm orovc.�demofish. - . i S ,ft fo cons}r�cf,alfer;Im ., �� �� `-acrcpalr ony�sl�ucture,�pNorto ils�lsiuonce;alsa re- � -- -�--� ---- � -� - -- VJIkIpIG� � - - .- , I '. quf�oslbcopplimntforsuchpermltfoH!nosfgnedstalo- . �- , V�' FPb'VERAUTHOR2[D_,-. � ' � .- � --'��"-- -� . . �.� . .\ `�. �' . � , i ment rfio�he 1s li�oneedpwsucm.�o ffic provislons al tne .:. �.�� �,` � ��� - - - ' � � onlroctori Llcenso Law Cf�o�far 4(com{nenc/ng wif7� i - -�- �� _.. , ,_ _ . _ /. Q�f _!... , � ��'� � -- - �'���' � � Sectlon 7C00}of DiWslon.3 0!fhe J3usinPss end Proles- � � Y�'�'"f � . sians Codo)orThol hc is exempt thcrc/rom and tho basis UTI!INCO.NOTIPtED� ' L� ; ���.(or Ihe oltegvd oxempllon Any.violauon of 5ecllon � __-- -.. . ._ .._.. . . _ . . . - FlNAL , �' � � ��� . �,---j---' � � ^-' � .. . ''� .� ....J03L5 by any eppOconi far a permit subjecls tha appli- . _____._..____ _-_...__. . +s�er orz rorsf-,�- . ,; : canJ to e civll penolty of not mere lhen liva hundred � :. � NOTES �., � '.. . .. .-..- _. . ' ' " do((ars SSGO).: '.-._. - . ..-.. •�. .... .. �... ,.�...• . . i '� . � �,�-' .:''' ' ... �_ . .' �-'-.. . ❑1...6i owner af tho p:operty will do 1F.e work.and�. � � � , . fhc struclum is�noi in!endod or offerod fo�salc.�- � � \'�,�' . � . . . , , : � .... .� __... : . __-. �- . r � (Sec.7044,3usirtass and Pio/essbns Codt: Tne Cvntroo � ... . , , . , ._ �. ... ...' , . . , � �� �� �.�or s L!enso Lcw does noe npp/y to on nwnvr ot propar� ;� .�. _ � ��.., - . . ; ��. � �. . . � wh kb'i(d� �r'lm � f__.- ��• "�, �.� '. . �. •. ' � j i � .__ '. � �- . .. �:.. � , p�ves fhereon, ond wh�does su�h � -�- .mzel ptovl ed lha�such�improdomenfs are no� � ." ...'� ._. . . .-. ���� '� �� '��. ' .- '-"�- ..'--�---�- ..._. .. . . -- __� . �.. Inlchdedcroflorndfnrsale.U.'however.�he6Wldingor ... .. _ .. . , . ..� •:��. . .... �. . . - - ..._. . .- ... ...... � . : ; .Improvemenl!e scld wilhfn ono yecr ol comple�ion.fho . , � , j � ��� � �� �� ownerbvifdorw711 have!Ne borden o(provin�ihaf he did . � � . . � � ,� _, , � � �. ,; . ,�,'.�_. ` '/.� . �...' - . ' ' ' � ' •'- ' �� �\not 6u17d or fmprovc for fRe ourposs oI sa7o.) " . ; ' .__.. __I. .._ .__._ I � r'�. . .__.__ � � . .. ... . _; .. ,. . . . _ . I am ezempt uader Sec. _.. __ �� , ,. .. . , . --.. _ _ ...._ , . .. , . . � -. _ __._, __ ___. . � . , _ . . � , . r--: _--.. _ '. ___6 E�P.C,f��r ihis reasen ' � � �� � .. � , _ . .�, � . r ' .' . ' O�te � . I . . . ... -- --.__. __�_�_ . ._ ..- O - - . -_. ' � - t � � �.r ... .. � . i , , . , � � � ... - - � . .. , ..,�.. . �, . _, . �- ���,..�., ; wner— . ,. . . ------ -- --- ' � . .��... . , , . . . � ' � � -�,�� .. ._ . ' .�. .��.�. . . .,.. - . . � . �_. � ... ,., • ,. . . .. . . .-.-'-'_._-- � .-..i�------� . .., . _ .�.i . � . . .. . . . , _� . , . _. .� . � _.. � • �, �, . . . . . - .... . .__.: � � . ....._ .---'--. -._.: i. . ... . : ..... „ -. -._.-'..,.-..�.."-'--i...____._.. _ . . ,_ .. . ._. . . ___ ...._. . _. . , . � �, � - : . � .. � . _ . , . , _. _ _ , ___-----,.. _._._.. -'.—.-;'_ -'--. . „ , . . .. . , . . , . ��..1-� i'�. .I � ' . ,. . . ,..; . � . , � . r . � , , , . . � ... _, . . ., � � " _ _"_� , ..� '� ' . . : . _. , . . , - .. . . .. __, . . � .. _._ ._ _ __ . . ____ � �' � ... ... � .. . . . . .. .. . , ....... ..... . .. .. �..,. ._ .. .... _ . ... `` `�t• 11�' �. . �� '. . \ _ \ ....