HomeMy WebLinkAbout0789A - WORKERS'COMPENSATION DECLARATION 76A663 �o�a, .qpp��CATION FOR ELECTRICAL PERMIT `�j �
I hereby aHirm tho�1 have a cenificote oF consent�o seif CE-Bob(' .
insure,o�a cartifitaie of Workers'Compansotion�nsuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY �1
, or a certified copy fhereof(Sec.3@00,lab.C.) "
Ocy No. � Company FOII ApLIGNT TO flll IN JOB �
Ceriified copy is heraby furnished. New Rasidemial Bidgs.8 Pools EACN NO. �{E ADDRE55 Q �� �/�. ��(fL
. � �Certified co is filed with the count bu�ld�n In ����TY -Zn
PY� Y 9 spec- I 8 1�Family,Sq.Ff. s — s L��'1G,v0 C--s%i
tion departmem. - . . Multi-fomlly Sq.FI. NFwaESt. L.
- . ResideMial Swimming Paols � � CRO555T. � d\C' � li�D'
Date APPlimn� OwNEROR .�(�.I� �f�JE
. FIRM NAME K— '
. CERTIFICATE OF EXEMPTION FROM WORKERS' �� � L�� � � MAi� -
� ' COMPENSATION INSURANCE � - - . Ootle�s:RetJ1_Light Sw. S t S C'�'
���Q� First 20 � ADDRE55 ILl/-�- f/J
, (Tb)s saN{oe n��d nat b�complNed ii 1h�work involv�d by Torol No.2mV CITY Tel.No.
, 16�p�rmit{s for on�hundnd dallon(SI00)or Int.) Additional 9
� I certify thot in�6e performonte of�he work(or whith thiz � . � q�ii MK • '.y`�
permit is iss�ed,I sFoll not employ ony persan in any mo�ner �+ ��
� , so as fo 6ecome subjact to Ihe Workers'Compensafion Laws. Lighfing Fixtures First 20 � +� ADORES ��j< ' ) r
Additionai
. . Total No.�� CIiY Te.No.��pl�.�q
� Oa�e �pplimN fixed Appliances Not Over 1 HP PERmIl
�, N0710E TO APPLICANT: If, aNar moking ihis Cartificate of a�liC4NT �—�'
Exemplion, yo� sho�ld became subjett to ihe Workers' Range_Healer_D.W._ �
Compensplion pro�isions of Iha Labor Code,you must forth- O�en _�ryer _W.M.— ADDRE 1�_� � �
� with comply wilh su�h provisions or lhis pe�mit sholl 6e Top _FAU —W.H.— �
deemed revoked. Hood _Fan _Orher CITY� - � Tel.No. -
� UCENSED CONTRACTORS DECLARATION �Dis ,Room Air Cond. �V+i. UCENSE OR w
, I here6y offirm�hol I om licensed undel piovisions of Chaptet 9 P' , � � RFG.rdU/�BER zL�3 �2 7 � � C���• �
.. (commenting with SecUon 7000)of Division 3 of fhe Business � : DISTRICT NO. PROCESSED BY
and Profassiom Code,ond my licanse is in full force ond eHetL Power Apparatus 8 Large Appliances _ , 4
- , . Size 8 Type HP,KW,KVA,or KVAR !7 Q �
, License Number. Lic Closs .. . Up to 1 Ind. - � FINAI . . V
� _ �Over 1 to 10 Inci. DATE VAUDATION �
� Controc+or ��a�e Over lO to 50 Incl. � - � ►�
, ❑ . � FINA! �
I om exempt onder Sec. Over 50 to 100 Inc BY �
6.8P.C.for this reason Over 100 V�
. . . Servicen Sw &P nelboords ► - ?
� Da�e: �A,rri. derE00 V � . .
Signature i-i000 n p.Unde�soo � <0 7�9 A-
� Enempiion for Reg.MaiM.EIecL ����� � �'�� •.� � O
- SINGLE FAMIlY � . Temp.Power Pote&Appurtenances
HOME OWNER-BUILDER DECIARATION Sign wiih One Branch Cirwit " � - .� �� � 9•O O
1 hereby oifirm thai I am e.empt from the Comrocior's License � `
Law for the following reoson($eUion 7031.5,Business and �+dditional Sign Branch Cirtuits .� +�.� Q Q� .
Professions Code): � � p�� 8_$5
❑ I,os owner of�he o ert Misc:Conduits 8 ConduUors � � - � � -�-
pr p y,will do tfie work(nd�he p�her See Com lere Fee Schedule
struttore is nal iNended or affarad for sale Sedion � P I— . � _
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY - . � . - -
, I hereby affirm ihat there is o construcfion lend�ng agenty for �
the performo�ce oi the work for which this parmit is issued PERMIT FEE - - � � - ��S�b-Total� � � ..- -
. (Sec.3097,Civ.C.). � ,J{�l-)7 - Q B
. PLAN GHECKING FEf sOq� ///� C�y,�/. .. .
Lender's Name (/
PERMIT ISSUING FEE . -
� Lender's Address �
I cerliiy that 1 have read this application and siate Ihm Ihe TOTAL FEE �
a6ove information is mrred.I agree ro comply with all Coumy .
ordinances and Siaie laws regulating Electrical w ing,and �
' hereby au+horize represeneatives of th�s County to emar upon -. � . , � �
fhe above-mentioned properry for inspecfion purposes. _ SEE REVERSE FOR EXPIANATORY IANGUAGE . ., .
Signa�ure of Permilree �ote .
_
. - OWNER-BUILDER DECLARATION
. � , APPROVALS � DATE � SIGNATURF � � � �
. TEMP.POWER POLE � . - I herc6y offirm fhat 1 om exemp�from tho Conlracfor's
- - - - Liconso Law�for ihe following�vason (Sacllon 7031.5,
. � , UNDERStAB WORK � � Bus�nass and Profosslons CodeJ:Any dryor rounry wh�ch
' ROUGH CONDUIT � -� � . . , _ reqvlres a permlt lo ronstrucl,aNe�,lmprava,demoHsh.
� or rvpolr any slructurc,prior!0 1Is Isswnce, afso rc-
_.._..._ _. � � ..'.� ..
. WIRING � - qufreetheappbcantforsuchpermi�toflfeosfgneds�ate-
� � . �-- FIXTURES � - � . , � " - , man}tha�h�le Ikensedpurmuant lo Iho provlslons o!the
- - „ - Confrocfort Llcenee Law(Choptcr9(commendng wlfh
- � ��- - POWER AUTHORIZED " � . Sectlon 7000J of DiNslon 3 0l�he 8uslness and Pro�es-
� - - � s7ons Code}or}hal ho fs exampt therelrom ond ihe basis
�-"- -� . � - UTIIIN CO.N071FIED� �� - � lor fhe afleged exemptlon. Any vtolofian ol Secllon
�- - �� PINAL . (� _ , 7031.5 6y any opplfcant for a porml�subjech fhe applf-
. C�nlar on��rortf con�10 a dvii penally oI not moro fhcn live hundred
- � �NOTES - - dollars(SS00J.: . . �
� _. . � , � , �� � � . ❑I,as owner o{fha proporty will do fhe work,ond
- �-� �� the strucivre ls no�imended or offered for solo.
� . - - � (Sec.7041,Bwfnesa andProlesslons Code: 7ha CaNroc-
- � - - � - � for's L7cnnae[ow doos no�apply lo an ownor of proporfy
- , . _ . � _ _,_ ' � . , who builds or Improves thereon, ond who does suc6
� � � . work hfmseli provfded Ihal such Improvemenis are nol
-� � - � In�ended or oilerod fo�sale.1!,howover,the buildtng or
. � -� � � -Improvemont fs sold wifhM ono year ol compleHon,fhc
- � owner-bulldorwtfl have iho 6✓rden olproving that he did
� - -- � - � � nof bWfd orlmprpve Ior thc pvrpaso af salv.)
� - I am exempt under Sec. � ,
� 8 8 P.C.for}his reason
. , _. _ . ' ... .._ . , - Date . . .
' ' � � � � Owner