Loading...
HomeMy WebLinkAbout1153A WORKERS'COMPENSATION DECLARATION 76A6N �o�e� � APPLICATION FOR ELECTRICAL PERMIT ;�� I here6y affirm Ihol I have a cenificofe of consenl to self CE-806G , � insure,or a certificate of Wo�kers'Compensation Insurance, - COUNTY�F LQS AN(�sELES BUIL�ING AND SAFETY � or o certified copy ihereof(Sec.3800,Lab.C.) � � �. Polity No. Company � FOR APPLICANi i0 Flll�N JOB f.^ . 1 ! - � Certified copy is hereby fornished. � New Residential Bldgs.8 Pools EACH � NO. FEE � ADORE55 � / !.�•. 7 ;. � Certified copy is filed with the munty building inspeo 1&�-Family,Sq.FL S = E LOCALITY � '. � � � tion deparlmen�. � - Multi-(omily Sq.F�. rIEnRESi ! � � Residential Swimming Pools � ow ER OR � � � ,J r - Date Appli[ant FIRM NAME.�-'� � r� .'�', �� 'CERiIfICATE OF EXEMPTION FROM WORKERS' Ou�lets:Rec_Lighl_Sw._ ��� ! ' ''I.�"'' � � �� � � COMPENSATION WSURANCE ' ADORE55..� ?"� _ % I . .�� .�.n Firs1 20 '� � (This s�ctien n��d net ba cemplolad if 1h�work fnvalvod by Total No. CITY � i��:��� Tel. �6��-�� �-'— '' �-}h�pormif is fer on�hundr�d dollon(f100)brl�ss.) - Additional '.�- PIAN CHECK �� I certify thal in 1he performance of Ihe w�k for which this , � APPIICANT � � � � permil is iss�ed,I sholl no�employ'any per�on in any manner so os to become su6ject to Ihe Wqrkers'Compensption Laws. lighling Fixtwes . First 20 ADDRESS .. � - � % � • Addilional � : ' -- � '�� ��.._. .` �.� � ! '�Total No. UTY Tal.No. Date� `•- ���� ^ � �opplitant� """'_� Fized Appliances Not Over 1 HP pEg,aii � NOTICE TO APPI�CANT: If, afte��makingr ihis�Cenifim�e of AppLICANt�' - i Exemption, you should become subject �o �he Workers' Ronge—Heoter_D.W._ � ' i� Compenwiion provisions of Ihe La6or Code,you musl forth• Oven _Dryer _W.M.— ADDRESS : ��+.i ,,.F ...- r;� with comply wi�h such provisions or this permil sholl be Top _FAU —W.FI.— _�_ ' deemed revoked. � CITY_�,, ��; ��. Tal.No. . -��J,'" Hood _Pan _Other_ �`^ ," : LICENSED CONTRACTORS DECLARATION UCENSE OR .� I hereby affirm Ihat I om licensed under provisions of Chapler-9 Disp. —Room Air Cond. — REG.NUMBER '� - ' Class ' �� �:� ' (commancing with Section 7000)af Division 3 of the Business ' DISTRICT NO. . PROCESSED BY � d � Power Apparotus 8 Lorge Appliontes and Professions Code,and my license is in foll force ond effeU. � r-�, � O i - . Size&Type HP,KW,KVA,or KVAR � !'� V �license Number� � Lic.Closs �� � Up l0 1 Incl. � FINAL � � . � ` � � Over 1 to 10 Incl. DATE , � VALIDATION � � , Contra`c�o:`�. � � Dare� - Over 10 to SO IncL FINAL o}e . ❑ I am exempt onder Sec. Over 50 to 100 Inc. BY , Q B.BP.C.for this�eason . �� Over 100 � � . � , � . � ' � � Services,Swbd.,MCC 6 Panel6oards � d Dale: 0-200 Amp.Under 600 V ' . .W- Signolure � � 201-1000 Amp.Under 6W V _ � , , . . r ' ❑ . � Over 1000 Amv.or Over 600 V . . , . Fr,,li,�+��;�.i'. Eaemplion for Reg.Moint.EIecL . .� � .4 � SINGLE FAMILY Temp.Power Po�e B Appurtenances - ' � �' �"'� � HOME OWNER-BUILDER DECLARATION �� '- x [ � . I hereby affirm that I am exempt from ihe Coniracbr's License $ign wi�h One Bronch Circuil (,c e;F.� �,� law for Ihe following reoson(Settion 7031,5,Business and Addi�ional Sign Bronch Circuits .o�,+�y�;_.r._;;� �, Pro(ess�ons CodeJ: , ,. . .C.*s.��. �. . � � . Misc Conduits R Conductors �, � ��- � � I,as owner of the property,will do�he work and the ��•���-��>�`'�^F^ . strocture is not intended or o4fered for sale �Section O�her(See Complete Fee Schedule)_ , � 7044,Business and Professions Code). -� CONSTRUCTION LENDING AGENCY . I hereby a(firm thof there is a construction lending agency for . � � � the periormance of ihe work for which this permii is issued PERMIT FEE � (Sub-Tolal) '� (Sec.3097,Civ.C.). � � . � PLAN CHECKiNG FEE � , . . � . . ' Lender's Name . . � .� . � � PEHMIT ISSUING FEE � � Lender's Address . � � � - ' � I certify Ihot I have read�Ihis applicolion and stole that Ihe TOTAL FEE _ �. , ' �above�intormotion is�mrreU.I aqree�o comply wiih all Counry , � , � ' ardinances and Siate lows reguloting Electrical wiring,and . � � hereby ovlhorizB�epreseNolives of Ihis Counfy 10 emer upon � Ihe above-menlioned properfy for inspection p�rposes. ` �� : ^�_,^,�-• ,v •f . SEE REVERSE FOR EXPLANATORY LANGUAGF � � i � SigqoNre of Perminee �Dote '� � � __ ' . .��..rmr�w� --__ -- -� -- T - ----- __.. _ . 7 , , . , � � .- �Ar, ,.: . . . , r'. ...`. � : r� r. � ... . ''. _ , . . � � ��- :?. ...c:,-:..... ;t... ._�.+. . . .. �.r:. .. ,�.. . ... .. . - � . , .� . . . � ., „ ,-.". .� . :' i -� ..__ ---� ._.._ ___.�. ._....__._..____.............. ...... . ____...... ..___._._.. .... ._-_" '_ . .._. . . ,. .._. .. . „ � . .... �. -;,. . _ ., _,_ . ._. ._. , _, . _- .. _---- �-- -- - - , . ... ---..__. _._; ._. _.._.__.. _ _ . .. . . _ _.__. . ., . . _. �- , �:. . . . , . ,.�� . .. .. . . . ' z . _ .. ._------- - . . . . i..--.. _._.__ .. . ._ _.. _._.. .. __ �:•- . _ �� '"` ... �.. -- _' - .._ .. " .-.--.. � . . .. . . , : . . _. .. . . . . � ��.. . � :, -,�• i � � - � ti._,__ . ----.._--------------- . .�._. _-� � �� � . . ... ' '" . . .. ----' � � : . . . . ,. � � ... ,a ' ,.�r . __. .__. ._...---�--------. _ �.._� . __ r��. . � ,�.. . .�,,. . ':,..,.i , ��.i.-. �....--- -- - �.---�---- ... __._. : . ' .. . � . . „ � T � ';r�_ � �� � . . . . . .,[ ' _. i -.� r ..� . . . . . ., .. ... ... , ... . ., . . ._..__----... ...._----� ,. �—. . _-...._..----- -- � . . �. , . ,.-._.' - .. -.�, rr. . � s . , . . . .. ........ . .. �.,. , . . �. -._.... �I ; . �, . .,. ' -- — ----- �------ ' �'-�'� � ' .,:.... . - -...�.. .., , � . . . .. .:,�. � .�.� ... . �� --.__. i � . i � �- I , � , '. . .-- '--^ --- i . , . .. � .. . , �. . . �. . . �. - , . � _. � ---..._ _-. . . . � � i �. .,_�„�! - . ---- - - � ---_ _..__ _ . . . S . _...__ . . --.-�--- __ . ., � . � . �1 `� � - . . ___. . .�. i .� ,�� . . i . „ . .. � . � , _. . -_ . . . . __. ___ _-- ___._ ._ � . . . , . _ . t .___ '. _ . , �3 _ .. . t � ,.,.. . � � � �, � . .. ., . .. . - , . � ..'__ .. _ . . ... __. _'_-_. ..:._ , , , ... � ]_ ._���_.___ _. ... - � � : .. ,t' .' ! _ . . . . . � . � _ j : . _..: .. , __. „ .. . �. . il � � � ��I� i .. "____ .. . _._ _... � . . __. . __ ..."" I ' ... . . . .. . � . . . ,J ... �.. .0"..•.. ...._..._.__ . � _�' i � __. - ... ..-� ,. � , .. ,... .. ___ _.. - -_.. _. _.. '.,.. . . . � .. , _ I _��� �-. �.. . . '•' . • . �. � I j _ .� ,. _�'. _ i ° �_. �_`��.-��. ._...v._ � . ' .. , .- .i .i ; .. ����.1 I .�.S �.. , '. ' ... . ,. ' . � '. ./.r i..�.. '�� � ' i ! � . .� .. . . . . . �. � / � " .-..._.._. .__.I -_.._ .... � i j •. . � _ .__ . .._..___ .._. .... . . � , .. . .. �i. � �� �_.' . � . ..._ ..__ ... ' r.�.. ..! l ...'. � . . _.. .__ ' . . . .... -.. ,� . . ...___ _. . _ .. , . ._ . . ��. . � . .. ... . ._ . . . ____'.____. � ' . . ._..�.__.....__.. . ._. � . . . . . _-_ -' � . ,.`i. . .._... . __ _ __ . ' �. .- : • � . . . I__ . . ._', >. .�. :. �. . __. _. ___ _' .. . . ._..._ _. _ .. ' ' 1� __' _ I „ � .. ` ., �.. _ _. . .__ . . . � . .. - _.._.__.___-1 '� _'_ -. __._ ..__.. . ...__ .. _ . � `__'._... _.._.-...__ . .. . � i � . � ,.;i��' i.i'.. ... �. - . . ... . ....... . ___ ':. . .... . __..___ � _ _1.__ _' .. .. __.. J(".�-: ..� .-..- . � . . - , • .. ., � , . . ' . I . � ... - . . , i . . � . i ,., .. . .. .., .. .. � . . .. . -- ... . .... .._ . _ , .. . . _ . . ..,. ,...,. � . : �., ,�� �.:� -. . . . ._.. ._ ....... . .....: .. . � � � . . � ,. - . ., I . � � � , .. . i � . � . , :.�..- � �' •- . , . �, . .� . . . . . .. . . . . � .�. �. . . -� ,._. -----...,_. .-----��- � - . --i, . , . . .. ` �1—._ . _. ,, . -. _ .. �i F _ '--1' . � ,, n _ :� k_ - _L_ ._.__�,._ _ ..�....�� . .. . . ,. . . . ,. I _ . � . � -�;.,. ..� .� :.-,_ .. ... , --_._ _. . __.__ __ . --.-- �" . �t- ---- r . __ . .. .. . . � i - , � ,_ ..,. . �,. - , - ' � - --�'-- '--._._._.—. .. .... . _.. . . , .. �. . .. .�. . . .__.._- ---- -- � � I � . , , ., � .,.... ..; i : � �:.. . ! ,. , � � . . � �-- ---— ` � --- - • , � _ ' �i. --__.. .__ -- � ---- - ' . �._�_.._... _.____�.._.._-----�.__..,.. .._�_�.::. �, - � _ . . , � _ � ,... -, ..-.�:,. . . � �.._.. ,