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HomeMy WebLinkAbout1036A . _ . .. _ ._.__..�_._.__, ,T_ _. . ... --..� ._ . --�-------�---_.-----__.__.. � WORKERS'COMPENSATION DECIARATION >I���oig�f � .APPL'CATION FOR EI,ECTRICAL PERMIT � - 1 hereby affirm that I have o cer�ificate of conseaf�o salf �� insure,or a tertifitate of Workers'Compenwtion Insurance, � COUNTY OF lQS ANGELES BUILDING/1ND SAFETY or a cer�ified copy th reof(Sec.3800,Lob.C.) ; � �� . ��Y�Sf��i3� Campany ��'�'�+'"�x � FOR NlLICANT TO iltt IN NO. FFE �RE55 �!� f�I'� ���'Vl� �Gi� Certified topy is he�eby furnished. lew ResideNial Bldgs.B Pools � S _ _ �ocnur ek.n -�`�-v��rv�oncl 13Hr'� Certified copy.is filad with the county build�ng inspec- �8�-Family,Sq.FL _ r.�qReSi �7 �' � tion deparimeM. � MuBi-family Sq.F�.� cRo555T. !p}'YIJH ����i�/ph(l Date qPP�i�a�� Residenlial5wimming Pools pWNEROR 1_� Un /, FIRM NAME � 1' ��) � CERTIfICATEOf EXEMPTION FROM WORKERS' � uflNs:Rec�Li9ht�5w.� . � A�pp�RE55 I/ G{� .� / J � COMPENSATION INSURANCE ,��y F���p (Thfa��e}Ion nwd no1 b�eomplH�d(f fh�work(nvolwd 6y Tmal No._.�L Additionol CITY W � [,�Tel.No. , fA�p�tmk Is for on�hundr�d doilan(f100)or I�ss.) p�qN CHECK � � I certify that in the performonce of the work for which this � A�ticANT � �� permit is issued,I Shall no1 employ any person in ony monner �AODRESS � � so as to 6ecome subjxt to Ihe Workars'Compensation Lows. �ghting Fixfuras First lU � � Total No.� Addiiional CITY - ' Tel.No. � Oate oppiimn� - ixed Appliances Not Over 1 HP . PeRmii /'�� NOTICE TO APPLICANT: if, ofrer making this Ceriificoie of ' APPUCANT C"y"�t " - � � Exemplion, you shoold berome subjed to the Workeri Range_Heater__D.W._. t y / Compensation provisions of tha Lobor Code,you must forth- Oven _Dryer _W.M.— ADDRE55 I�Z i' • 1�`.Ij 5f` `j ' with tomply with soch provisions or this parmit shall be top —fAU W.H.— CITY �� I p-�,Cl ��� Tel.No,� -y(�j " daemed revoked. Hood _Fon .�o..O�her_ � tICENSED CONTRACiORS DECLARATION . � LICEtaSE OR 3 �((�(6 � ��Qu ���� '�� �I hara6y offirm that 1 om lice�sed under provisions of Chopter 9 Disp. _Room Air Cond.�— REG.NUMBER DISTRIC7 NO.� PROCESSE BY � (mmmencing wilh Section 7000)of Division 3 of the BuSiness power Apporatu5 8 Large Applionces � - d .ond Professions Code,and my license is in full force ond effect. . �� ,u� p r }��/�/./ � � . /�/� Size 8 Type HP,KW,KVA,or KVAR� � license Numbe S fyT�P Lic.Class �� - p to 1 IntL FINAL� �� I � ) � r. ��.�� i ���Ovar 1 ro 101nt1. DATE 1�{tl�, VALIDATION 0 Contrac�or FiPFOI .,�1?1'/liL�.pateJ____�— l ib Over 10 to SD Ind. ~ ❑ FINAL W I am exempt undar Sac, � Over 50 to 100 Inc. � BY `1,�ll�t y �� B.BP.C.for Ihis reason Over 100 = : pa� Services.Swbd.,MCC&Panelboards � d ► ; ]j'�'�"� 0-�00 Amp.Under 600 V a � 5'go�n�r. _ ���7�YiJ�tML 201-1000 Amp.Undar 600 V . . . . . ❑ 1 ' Over 1000 AmD.or Ovar 600 V � _ . . . - Exempiion for Reg.Maint.Elecl. � SINGLE FAMILY � . Temp.Power Pole 8 Appunenances � � � �1 p 3 6 A HOME OWNER-BUIIDER DECLARATION Sign wilh One Branch Circuit I hereby affirm that I am exempt(rom the Contw<tor's license qdditional Slgn Branch Circui�s � � - �'�' ' � �2 Law for the foltowing reason(Sec�ion 7031.5,Bvsiness ond �. ' Professions Code): � . : �. ... ..-.� •3 4�1 S� . ❑ 1,os owner of Ihe properly,will do Ihe work and the Mis�.Conduils 8 Condvclors - � � , . struclure is nof inlended or offered for saie(Section Olher(See Complete Fee Sthedule)_ ► .• ..3 4 Q 5 b� � 7044,Bvsiness ond Professions Code). , ; _D 1.1 3--84 CONSTRUCTION 1EN01NG AGENCY ��� � � I hereby affirm iho�there is a consirucfion lend�ng agency for ' the performante of the work for whith�his permif fs issued � pfRMIT FEE � �- - . (Sub•Toial) (Sec.3097.Civ.C.). � ' . - -� PLAN CHECKING FEE �- � � � , � , � � Lander's Name � a C PERMIT ISSIJING FEE . . � � - lender'z Address TOTAI FEE � J'y . � � � � � � � � I certify ihat 1 hove read ihis opplicotion and sla�e thot the � � ' - ." � obove information is corre<t.I agree to comply with all Couny . , � ordinantes and S�a�e lows regulating Eletlricol wiring,and _ . . � �� � -� - �� heraby authorize representaiives of this Counry to eniar upon � � the ove- n�' ned p rry f inspet�ion purposes -SEE REYERSE FOR EXPLANATORY IANGUAGE. � - - � � �- - ��`� /-/3-�� . $ignarore of Permitlee Da�e � - - . . . . . .. . . . ..,__ . . � . I . . . . . � � � . . . . ' i . , �.'; ' �.,, . .'I APPROVAlS --�'DATE �.. � S�G�R� . . ._. . � .�` .� OWNER-BUILDER DECLARATION�.'�`• � - � TEhtP.PQY,$R FO�E � � - � I herahy otfirm�hot�l am eacmpt from thc Contra<ror'a ._ , � ��. ' UNDERSLAB WORK � 3 - .� I Litense law !or Ihe following rcason.(Sec/lan 7D31,5, , --� � � j BwlnessVrdP�olesstonsCodvJ:Anydlyormunsywhich � , _ ROUGH CONDUIT � . � " � raqulres o permlt�o construc�,olier,fmprovo,deme!lsh, � , . WIRING � � Sj 1� or rvpo�r arty sfructurc,prlor 10 Ils/ssvancc, o/so re- . . ' qulreslheopphcantfors�rhpermlrfoilleasignedata�e- FiXTURES �- � - mrn/fhotholsllccrtsedpursvanJfofhcprovieionsolthc - �--- - �� --� - � �Conlraclorb Llcense law(Chapter 9(commonctng wlrh � POVJERAU7HORRED - � " � � " � - � � � Secflon 7000J ol Dlvlston 3 0l lhe Buslness and Proles- � � --- - - UTILIiY CO.NOTIFIED - � � stons Cade)or fhof ha Is exempt lherefrom and Ihe bos�s �� � c7 . �/or fhe al/eged exemplion. Any vto/o�fon o1 SeUion , � F�NA� �4nfer bn'.yronf � ; 7031.5 by any applfcane/or v permit su6�ech fFe appli- - - -� -� NOTES � . � �. � cent ro a Nvll pcna(fy ol nof moro fbon flvo hundred , . � . , �� � . . ' do!(ors(5500).: , �-� � - - � � � � � . ' � :❑1,as owner of tho property will do�he wark,and - � . � � tho s�ructuro(s no�lntended or offcred for sole. . � - --� - � - � � - I ($ec.7044,Sus(ness and Pro(osslons Code:� 7he Confraa - , _ _ � . _ _� . foi s Llrense Cvw does nol opp7y 10 an owrtcr of prcperly � � - - � � - - who bullds or lmproves fhereon, and who does such �� _. ,.. . . ' work h7mscit provided tfiat socb improvemen�s ore no� � � � , �1Nended or oflered(or sale.If,howevcr,fhe building or - improvement Is sofd wlthlrt ono ycar o/compieHon,Ifie . -"-�- � � � ' ` . - � . . . ownet•buflderwilfhavethebbrdenolprovin�thathedid ; not 6uf7d or fmprovo for fhe purpose of sole.J ' 1 om.exampt�nder Sec. - , -.. . .. . . B 8 P.C.for this reason . . . � . � . Date�., ' ` _ • � Owner � � . . . . . i , . � �. - ._ ._ . . ,_. } . �. . _ '