Loading...
HomeMy WebLinkAbout1037A (5) _______._._.. ._..__._ , _ _ .: ., .... _ _ ._ .._. ._ , WORKERS'COMPENSATIONDECLABATION 76A663 �o�e� �� APPLICATION FOR ELECTRlCAL PERMIT }� � I here6y affirm thar I have a canificare af consenl lo self �E'�� �� insure,or a cerlifimte of Workers'Compensation Insurance, - COUNTY OF LOS ANGELES /,� BUILDINCs AND$AfETy ��� or a cerri��/L��Qyf(Sec.3800.lab.C.� � . . l: P�o�icy No. � Campany�� � � FOR A►PLICANT TO flll IN q�ppRE55 — '� tn f - Certified copy is he�eby fumished. New Residemiol Bldgs.8 Pools EnCH NO. FEE '� � ��Cenifiad copy is filad wilh fhe coonry boilding inspeo-. �g 2-Fomily,Sq.Ff. s � — S LOCALITY pµ,�1[�,e �� ���-Gt�4 ��/;W�nd � lion da rtmenL �� � Molti-famil S Ft. — NEARE57 n r � � � � Residenlia�Sw mming Pools �u 57.}l��o,�td r�,< Gra-�d � $ . Date Applicanf - � OWNEROR _ . CERTIFICATE OF EXEMPTION FROM WORKERS' � �� (� (� . FMtRnM NAME O �'ISU�I_ � � COMPENSATION INSURANCE .- Oudets:Rec_Lig4t�Sw..,,(._ q�E� � • ' GDA �7W (This a�cflon ne�d not b�tompbad II ib�work InvoWed b� ,—/ Firsr 40 , /h�p�rmif{s for one fiundnd dollan(5100)o�I�s�.) Toial NolL� Additional CITY�Fc�N � �Y'�. �el.No. I cartiFy Ihot in�he performonce of ihe work for which Ihis � - AppN�MK � -permil is issued,I shall not employ any person in ony manner � . . � so as to betome subjett b the Wwkari Compensation lows.� Li9hting Fixfures,� Firs�YO ADDRE55 �� . � . . . To�ol No. Y ' Add��ionoi � .. . . . Da1e �oppiicont � � CRY Tel.No. , NOTICE TO APMICANT: If, otler making Ihis Certificale of Fixed Appliances Not Over 1 HP pfpM�T � �CL�r I Eaempfion, you should 6etome subjact lo the�Workers' Ronge�Heoler_D.W._ A7PlICANT � �-- '. Compenwrion provisions of ihe lobor.Code,you must farih- Oven _Dryer _W.M._ ADDRE55� ZC� w,11'�. �-, G ith comply 'th such provisions or �his permit sholl be Top _ _FAU� W.H.— ' deemed revoked . . . - CITY �. ,�.�� �tp. � TeI.No. �I'u S^ LICENSED CONTRACTORS DECLARAiION Hood —Fon �Olher_ -0isp. _Room Ah Cond. — LICENSE OR ���I// �f .Class, r`-f 1 hereby affirm fhat I am licensad undar provisions of Chop�er 9 , REG.NUMBEk Y�v�� �commencing witb Setlion 7000)of Division 3 oi the Businest power Apparotus 8 Lorge Appliantes . � DISTRICi NO. � PROCESS D BY � and Profess�ons Code,ond my I�cense is in full force ond eff ct � � � � � � d Size&Type HP,KW,KVA,or KVAR� -�0 O license Number 3��`�6�- Lic.C�ass �yl ... Up to 1 IncL � FINAL - . . . . . �J co,,,,o�,,,FREO J �%hG'Ci'4 Da�e �I� ��Over 1 to 10 Ind. DATE (�V��� VALIDATION O ❑ Over 70 to 50 Ind. a . � F- FINAL 1 l am exempi under Sec. Over 50 io IOO lnc. BY �'��t ,�� , � ��� N B.&P.C.for this reoson Over 100 Z � Services.Swbd.,MCC&Panelboords ` � � � 0-200 Amp.Under 600 V Sa��r ro . � 201-1000 Amp.Undar 600 V � . �. . . ❑ � Over 1000 Amp,or Qvar bOp V � Exemplion for Reg.Mpint Eleti. � . 51NGLE FAMILY - femp.Power Pole 8 Apportenances _ � �'� Q�j,]r{ � HOME OWNER-BUILDER DECLARATION Sign wifh One Branch CircuH � � � i hereby affirm that I am exempt From ihe CoNroc�or's llcense Additional Sign Branoh Gircuits #• '�' • •2 Gaw for fhe followinq reason(Setlion 7031.5, Business ond -� ' � � � Profession5 Code)� � � e 3 S 9.0 0 ❑ t,az owner of the property,will do the work and the Misa Condui�s 8 Condudors - � � � � � � . - -���� � strucrure is not intended or offered for sale(Section Ofher(See Compleie Fee Schedule)_ ► . �• �J�9���� 7044,8usiness and Professions Coda�. ��,� 3�$4 CONSTRUCiION LENDWG AGENCY . ' . . - . . _. . . I here6y offirm thot Ihere is a constrottion lending agency for '. ' the performance of the work for which this permit is issued PERMIT FEE - � - - (Sub-Toml) � �. . _._ . (Sec.3091,Civ.C.). . . . - . � PLAN CHECKING FEE �� � _ . . . . . , . tendei s Nome � - � PERMIT ISSUING FEE ._. . . . Q . -_ , ' Lender's Address . � � � 1 ceriify Iha1 I hove read this applimtion and state thof the TOTAL FEE �S9� . . obove informmron is correct.I og�ea to mmpiy with all Counry � � �- � � � �""��- ordinonces ond Srate lows raqulafing Electrical wiring,ond � � hereby authorize represen�atives of is Counly�o en�er upon � � - � - �' � � � �� - � � � Ihe ove-m ne ty(or spettion porposee. � - � ��p SEE REVERSE FOR EXPIANATORY LANGUAGE -��l�l� —/3—� _ Signature of Perminee � Date �� . _ _ _ . _ - � • ,�� � -� ��t,PPROVAlS DA7e � , . OWNER-BUILDER DECLAP.ATION .. � SIGNATURE . � � . � � � TEMP.POWER POLE � �- � '. - I hereby affirm Ihot I om exampi irom the Conrrocfor's �. � � � License Lew for ihe following reason (Section 7031.5, � � � . . UNDERSIAB WORK � . . � Busfness ond Professlans CodeJ:Any cify or county wAlch . � RDUGH CONDUIT . � � � reqUlres a permlf fa rortsfrocf,altrr,Imprave,demolish, . _ orrepalr any structure,prlor to Its Issuvnce, olso�r � WIRING . . � - � . . qolrestheappl�mntforsuchpermi�tofileasignedstaie• � �� � -�, - FIXTURES �' ' � . . � menf fhal Fo Is Btensed pursuanl fo}ho prov7slons of Ihe , . �.�ConlrvUori Lfeanso Law(Chopter 9(commencln�.with ��"-� � POWER AUTHOkIZEO � ' '" � � - � Socllon 7000)af Divftlon 3 0l ffie 8�sfnezs�.and Proles� � � � s/ons Code)or fhal be Is exempf fherelrom and fhe bazis � - - —� � - - UTILITY CO.NOTIFIED � !or 1ho olicged oxemption. Any violallon ot Secfian ` - FINAL� -- ' c7 � � � � � 7031.5 by eny appheant for a permR subJects Ihe appfi- � ";'"'� -'"- ��� " " �rtici on.�`ront ; �p�f fo a cWlf penalfy o(nof moro Ihon llve hundred �- -��-� � - � NOiES � . . dollars(SS00J.: � � • . � - ❑I,as ownor of tho property wiil do the work,ond � -�- - � ' � � the shactore Is not imended or offored for sale. � - - , � ' � � ' - � � (Sec.7044,8uslnessandProfesslonsCode: ThoConfrac- ,_.. _..-_ .. .: . _.. _.' .: . .. ! . . � �� for's Clcense Low does nof apply fo on owner ol properly � � �__ .._ ., �,� __� �.• _ � , � � who bollds or fmproves lhereon. and�who does such � � � work hfmsel/providr.d ffiat such Improvements are no� , _�_ . ._..._. __. _. . . . . ... , � � . � mtandederaHeredforsafe.f/,however,lhebutldingor � � �� ' ' � Improvemenf is so7d w7fhln one year o�compleflon,Ihe , , � � , , � . ownorvbu1lderwillhavefhe6urdenofprov(ng}halhedid � - � �-- ' - � � � , �not bulld or Improve for 1ho purposc of sale.) _ '''' � ' �I am exempt unde?Sea� � - ' --� B&P.C.for this reason � � - - . . . . � �bafe� . . .'-. . Owner ... ' . � � � -