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HomeMy WebLinkAbout1822A � WORKERS'COMP[NSATIONDECLARATION 7hA663 70ie1 Ap.pLfCATION fOR ELECTRICAL PERMIT � � I here6y affirm that I hove a certifimle of consent to self CE-806G . ' insore;.or a certiflcate of Workers'Corope�sation��surance, COUNTY OF LOS ANGELES BUILDING AND SAPETY or a certified copy thereof(Sec.3800.Lab.C.� � P❑ol�icy No.b�+�g_Company��'���'v�� FOR APPLICANT 70 FILL-M� - Jpg - �� �.`�� + ��,, Cer}ified co s hereb furnished. EACN NO. FEE ADDRESS �� , �_ . .PY' . _Y NewResidentialBldgs.&�Pools LOCALITY.bl.�y��y�„y—� '��_, Certified copy is filed with the county building inspec- 1&2-Family,Sq.Ft. � — $ . � � tion depprfinent: � Mult-fomily Sq.Fi. — NEAREST �� �+.� CROSS 5T.,�D C��'''� � �'�'"�-�51_.!I J> Residentiol Swimming Pools - � Dqte��.�._Applimnt ����"w��-� OWNEROR - � ��. � FIRM NAME ��-����� CERTIFlCATE OF EXEMPTION FROM WORKERS' 9 Mai�_ j��,-' �,- -�,�����,�- � � Ouflets:Rec_l.i ht_Sw_ � - - � COMPENSA710N INSURANCE ADDRIESS I r .;—� (This secfion�need nol be completed if the work involresl_ky_ First 20 . _ - ili�perm�is for oneTion�d dollars(j100)or less:) -�ititafNo:� -�-Add honal CITY�(/Q�y"�'��'� �'j�.No. �� PLAN CHECK � I certify rhat in ihe performance of the work for which this qpp���qNT � �(7' j.J..--1.,...f-��,_. permit is issued,I shall not employ any person in any manner .. � -. � so os la become subjecf fo ihe Workers'Compensafion Laws, Lighfing Fixtures Pirst 20 ADDRE55 - - Total No. Additional - CITY . . �. � �I.No. �ate ApplicaN Fixed Appliances No�Over 1 HP PERMIT - NOTICE TO APPLICANT: If, after making this Certificote af , APPLICAMT�I��"�" ^� t�� Exemption, you should bemme subjeci to the Workers' Range,Heater_D.W._ � Compensation pravisions of the Lobor Code,you must forih- Oven _Dryer —W.M.— A�DRESS�f�, ,����. �r�y�.� 1�.(S�zQ wifh comply wifh.such provisions or fhis�permif shdil be iop _fAU �W.H:— deemed revoked. � - CITY(..�'lA�����" Tel.No.C�^y/.�:L�cl,c LICENSE�CONTRACTORS DECLARATION � Hood _Fan _Other— . . � LICENSE OR /�y�^� I here6yafrirm fhaf I am licensed under provisions of Chapler 9 Disp. —Room Air Cond. — REG.NUMB���O e.� Clqss.G. ,�f� � (commencing with Section 7000)of Division 3 of the 8usiness DISTRICT NO. PROCESSED BY �.� and Professions Code,-and my license is in ful�force and effed. power Apparatus&Lprge Applipnces . Size&Type HP,KW,KVA,or KVAR- �� � ,_,.._�--- License Num6er '����� Lic Clpss ��� Up fo 1 Ind. FINAL �= Over 1 to 10 Incl. DATE '� Conirador�IG>I�J—t�/�'�� Date . / �.1.� iDAT10N . � ❑ Over 10 to 50 Ind. FINAL - Is1 I am exempl under Sec. Over 50 to 100 Inc BY � B.&P.C.for this reason Over IOD , � � Date� Services,Swbd.,MCC&Panelboards , . � � 0-200 Amp.Under 600 V Signature � 201-1000 Amp.Under 600 V � Over 1000 Amp.or Over 500 V . Exempfion for Reg.Maint Elect. j.� �LZ,�� SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARF:TION Sign with One Bronch Circuif � � � '�'� °�� ° °� I hereby affirm that I am exempt f�om the Coniractar's License qdditional Sign Branch Circuits � Law for ihe following reason (Seclion 7031.5, Business and �� � e �(j�j,tj Q Professions Code)r - - � � � Mise.Conduits&Condueiors � � ea,c.a[I,.c�,j i�� I,as owner of the property,will do the work and ihe ' . strudure is not intended or oftered for sale(Section Olher(See.Complete Fee ScheduleJ_ � � 7044,6usiness ond Professions Code). C���"��� CONSTRUCTION LENDING AGENCY � - - � � I hereby affirm that there is a construction Iending agency for ihe performance of ihe work for which this permit is issued PERMIT FEE (Sub-To�al) �� � - (Sec.3097,Civ.C.). � - � PLAN CHECKING FEE - � Lender's Nome PERMIT ISSUING FEE �� � - Lender's Address � ��� - . I certify thot I have read this applicalion and siate fhat the TOTAL fEE - above information is mrrecf.I agree to mmply with oll County ,� - , � ordinances and State-laws regulafing Electrical wiring, and � � hereby authorize representatives of Ihis County to enfer upon � � - � . �e-mentioned p^roperry nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ~���»L� �s' /��� Si�nature of P mitiee Dote t € � � t g � � � � 9 _� � � i �. � � I � , � � � ! � � � , � j jj � __ —� � � 3 � � � 4 E � � � ; � � � � � '{ ( � � y C & � { 1 � i e � � � � i ! � j � I 1 jF � i (� E r) � k i f � 9 � S � � � I i � 4 � $ � � € i � � [ i i � I � � � � i i �� � � � ��� (� � � � ' � � � � i � � � � � i i � � . � � � � � -. . i � ' � �� � , 3 � � � � � � � � €� x � � ; � ' � � : E t * � i # � � ! € � � � � � i � � ? � , j � - ( ' � � � � ' i j � i � � ' � �- �( � � �-`�- � �-���-----E j] � f: s � � � � � ( € .�;� �j � [ �, e.� ��� � � �€w, �� �� , � � t I � s � � �( _ � . . _� � ] _. 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