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HomeMy WebLinkAbout0776A WORKERS'COMPENSATION DECIARATION 76A663 10i8t qpp��CATION FOR ELECTRICI�L PERMIT � I herehy affirm tfiat I hove o cerrificme of consem to self cE'806('' � insure,or a cenifkoee of wo�kers'Compe�saron I�wm�cm COUNTY OF LOS ANGELE$ BUIIDING AND SAPETY or a c fi�dS�Jppy_Iher .3800, b.C.} � . ' � Policy�D� o � � FOR A►PLKANT TO Flll M � JOB {S `❑�..Cariified copy is hareby 4urnishad . New Rasidenliat Bidgs.8 Pools Fn[H No. pee AookEu ! �Certified copy is filed with theb/d�nty ilding nspec- 1 8 2-Fomily,Sq.F�. s = t IOCALITY � tio deppn L•/ � /�/! Multi-fomily$q.FL NEnREST µ �'C �,.� � Rasidentiot Swimming Pools CROSS S7. Date I� IApplimM `�' � OWNER OR � F RM NAME . CERTiFICATE OF EXEMPTION PROM WORKERS Outlsts:Rec—light_Sw:� ��� � � GOMVENSATION INSURANCE Firs�20 ADDRE55 � (Thh s�dlon ne�d no1 be compl�f�d H fh�work inrolwd by Total Na. Addifional � QTY � Tai.No. 1h�p�rmit h fer en�Aundr�d dollen(f100)er I�u.�' aAN C�EGc I certlfy thor in rhe performance of the work ior which�his . , ARM�Ce,M - �� � - � permit is issued,I sholl not amploy ony person in ony ma�ner so as to bacome subject to the Workars'Compenaoiion laws. lighting Fixtures Firsf 20 AODRESS , � � � Totol No. � Addirionol CITY � � Tal.No. Dote oppliconf fixad Appliances Not Over 1 HP � PERhvt . NOTICE TO APPLICANT: If, ofter making this Certificoie of � APptiCnNT � Ezemp�ion, you should 6ecome wbjeU to the Workers' Range_Heo�er_6.W._ ' Compensouon provisions of Ihe lobor Code;you must(orlh• Oven _Dryer _W.M.— ADDRESS � ith mmpiy with such provisions or 1Ris permit shali be Top _FAU —W.H.—._ . daemed revoked. � Hood _Fan _Orher, CIiY - �� ��TeL .- � LICENSED CONTRACTOR$OKLARATION - � UC�NSE OR 1 hereby affirm Ihat I om litensed vnder provisions of Chapler 9 Disp. _Room Air Cond. — REG.NUb�BER '� C� � (commencing wiih$ection 7000}of Division 3 of ihe Business DISTRICT NO. � PROC EO BY ' ond Proiessions Co a m I11'cense is in full force ond�yffq�t. Powar Apporotus 8 Lorge Appliancas � , ., � . �)�I�/.� �LL1,1/. Size 8 TNoe HP,KW,KVA,or KVAR u � License N ber T Lia Class T,I r � FINAL � � � - _[__ Up to 1 Ind. ' ComraUo Date� �S , Over 1 to 101nc1. DATE .���6'.��ly(_ VALIOATION p . ❑ Over 10 to 50 Ind. FINAL . .. �1 am ezempt vnder ec. O�er 50 to 100�nc. BY. . �j, � B.BP.C.for ihis reoson OVB��� ,' � z Do1e: Services,Swbd.;MCC&Poaeiboords � . � : � ' � - �- — � 0•4O0 Amp,Uoder 600 V . Signawre 201-1000 Amp.U�der 600 V � �� - , -� - � � ��, O . . Ove.1000 AmP.or Ove�600 V . . ., _ . E+empiian for Reg.MainL Elect. � . . . ='_C!f.�F SINGLE FAMILY Tamp.Power Pole B Appurtenances � HOME OWNER-BUILDER DECLARATION Siqn wiih One Bronch Circuii , $�" • • •� I hereby affirm tha�I om exempt irom ths CoN�actor's litensa Additional Sign Bronch Circai�s � � - , - • � , low for the following reoson(Section 7031.5, 8usiness and � , I � •�� L',.�,:G � Professions Codej: . . - � � ❑ I,os owner of the t M;sc.Conduin 8 Conductors � � ��,, � . . o e'� �;..�('�;;T�- proper y,will do the work ond the� p�her See Com lele Fee Schedufe_ " sirocture is noi(Mended or oHered for sole(Sedion l P ) ' 7044,Business and Profassions Code). ► ' �G L�1-��l � CONSTRUCTION LENDING AGENCY . � � � � � � - .� , I hereby affirm that there ts o construcfion lending ogency for � . ' ' Ihe parformance of the work for which this pe�mit{s issued �� pERM1T FEE � , � - (Sub-Totol) �� �- -� � - � (Sec.3097,Cfv.C.). � � � � PLAN CHKKtNG FEE . � � � , � . . . . . ' ... Lender's Name � ' � � ' � . -- � ' PERMITlSSUlNGFEE . . Lender'sAddrezs � � �� � 1 cerefy Ihat I have reod this applicolion and sta�e that the TOTAL FEE � - � , obova informotion is cortecl.I ogree to�omply wilh oll Counry � � � ordinontes�j�d Siate laws regula�ing Elactrical wiring,and � � � � hereby outJ�o'iz epresentativas of thls County to eoter upon � . , � � � � the obov�n n�erry for inspection urpos s. . . . �. � . . .. . . � � ,� � �SEE REVERSE FOR EXPLANATORV LANGUAGE Signoture of Perminee Dc1 � ' � � _ _._ . , • . . . � ' . aPPROVAtS. .. ..DATE._ . .. . ..�' . .... .... . �. ,. � OWNER-BU1lDER�ECIARATIOU.�� ' � ` SIGNATURE- � � � � � � - - - - . , . ` 7EMP.POWER POLE�� �� � � - � �-����- � � ` � I hore6y affirm�hat I am exempt�from tho Conira<tor's - � - � � -- � - . - � - � ' ' - � � � litonse Law for iha following reason (Secllon 7031.5, � � UNDERSLAB WOP.K ' . . . . �. 8usfness and Prolesstons Coda):Any cioyor couNywhich� . � . � ROUGH CONDUIT � � � � � � . � reqGfres a pormll to mnslrucl,aHe�,improve,demolish, _ • � . -arrepoir'ony atrorfurc,prlor lo Ns/ssuance, olso re� WIRING' � , . � qult�stheappllcunllorsutbparmlflolllevslgnedsfafe- ' � ��� ��-� --- fIMURES � ... . � mml that hels bcensedpvrevan�ro fhe provlsfons oi fho , �� Con�rottor's Llreuo Law(Chopter 9(commencing wNh -�� � -- - -� POWER AUTHORIZED . - � - -� �--� � � �� � � ` Soction 7000)of Dtvlslon 3 0l ihe Boslnoss and.Proles . . slons Code)or Ihaf he Is exempt fhercfrom and�he bosls � , � - . -- '-- - - �UTIUTYCO.NOTIFIED�- � � � lor fho aflvged oxempRon. Any NofalJon of Sect/on , � � PINAL �Gnfc�on�yron( ' � � � 7031.5,by ony appllcant Ior a permit avblects ihe opplr- , - � - cant fo a dWl ponalty o(no}moro fhan f)vv hundred � �. ....- ... .. .NO7E5 . - ' - � � - - �� doflors(5500).: , � � , � � � " � . ❑I,as pwner.of tha property wtll do ihe work,and , � � - � - � iha etructure is not Intondad or offered far sala � � . � . � , . - � -- � (Sec.7044,QwfnossondProfossionsCodv: 76eContrao �_. . :.. � ' � '� . . . -..__ __.. . . lor's Llcenso law doss nof oppfy to on awner of properfy � � ._ , - . � , � .. - �, wha buifds or lmprovos ihcrcon, and who does such � ' � � ' work himseH provlded Ihat such tmprovamon�z aro nor � � �� — - - - - , � �tnfended or oflered for sale.If,however,1ho bWlding or � � ' ' � � ' � improvement le sofd wlthln one year of complaflon,fho � � . ' . - - . . . _ , � � , . , ownerbWlder wlll havc}he burden ol proving fhol he dld . - - -- � � � � not bu0d or fmprovs for fho pwposc of salo.J ' �� � , .. ' - .. . . . . ..� � �.. ;.._. . ,J am exampt vnder Sec. ' . � B 8 F.C.for ihis reason �� � . . . __.�, . . . . _._Date � . � � � � Owner " � � , . , i.