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HomeMy WebLinkAbout1692A ,J - - — �_._. . _ . _.._ . . _ / .15'ORKERS'C0�IPENSATIONDECLARATION 76A663 APPUCATION FOR ELECTRICAL PERMIT � � CE�e06G(2�80) � heretiy ar�irm that � have a certif�cate ot consent to se�t COUNTYi7f LOS ANGELES BUILDING AND SAFETY insure,or a certificate ot N'orkers'Compensation Insurance,or , - � a certified copy thereof(Sec.3800,Lab.C.) ' FOR APPL�CANT TO FILL IN Jpg � .. '� Policy No. Company ADDiiESS U .. � New Residential B�dgS.&Pools EACH NO. FEE � Certificd copy is hereby furnished. 1&2Family,Sq.Ft � — S �OCaUTY ' � Multi-family Sq.Ft. — N A S � - � Cer[ified copY i�filed with the county building inspection Resitlential Swimming Pools CROSS ST � 1.�. I department. '. � O'RNMENAME 1 � Date �APP��cant Outlets:Rec.�Li9ht_Sw.� MAIL ' /f First 20 AODFESS CERTII'ICATE OF EXEMPTION PR0�9 W'ORKERS' Total No. "� Additional CITV � Tel No. } � �� � COMPCNSATION INSURANCE , PLAN CHECK a � . . . APPLICANT �� � � (This section need not be completed if the.woik involvcd V by the permit is for one hundted dollars (5t00)or IessJ LightingFixtures . First20 qooRess r G .G{ L ¢ Additional � I certity fhaT in the Derformance of the work for which this F xed Appliances Not Over 1 HP CITY � �e_ Tel No,s C27s� � permlt i.¢tssued,t ahall not employ any D�rson in a�y manner PER�vtii � U �'. so as to become subject to the 14orkers'Compensation Laws. Range�Heater D.W._ � AVPLICANT a � C Oven �Dryer_W.M.� � AODRESS � 3—�—y Z � �,� Top _F'AU _W.H._ � � � Date ADP��caM CITV ' Tel No. � Hood—Fan _Other_ NOTICE TO APYLICANT:IL after making thi'Certificate of Disp. _Roam Air Cond., UCENSE Oq - � Exemption, you should become su6ject to Ihe W'orkers'� REG.NUMBER 369/3/���. i Compensation provisions of the La6or Code,you must forth• power ApOaratus&L.arge Appliance5 � DISTRICT NO. PROCESSE�BV � � with wmply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR deemed revoked. - � u,u� � � Up to 1 Incl. � .Over 1 to 70 Incl. DATE r� , , LICENSED CONTRAC7'ORS DECLARATION Over 10 to 50 IncL � �l� �` VAUDATION . ' I hereby affirm that 1 am licensed under pravisions of Chapter OVe�BO to 100 InC. eY pL • 9 (commencing�vith Section 7000)ot Division 3 of[he Busi- Over 100 . rl���� � � ness and Professions.Code,end my license ls in fut]torce and . , � effect. / � Services , � � � �. License Numbe v��� 'Lia ClasS "� ' 0•200 Amp.Under 600 V . �i 201-1000 Amp.Under 600 V � ! �' ContractorJ;���I��Date ���U�— Over 1000 Amp.or Over 600 V - . � HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances � . .. � I hereby atfirm that I am exempt From the Contractor's Sign with One Branch Circuit . . � Additional Sig�Branch Circuits �� 6 9,,2 a � License Law for the following reasan(Section 7031.5,Busi- . � r ness and Yrokssions Code): . � ' � � . � , . MiSc.Conduits&Conductors ��� �.�.�.�'2 . � l, as owner of the property,will do the work and Ihe pther ISee Complete Fee Schedule)— � � ` struc[ure ts not intended or offered (or sale (Section � �I�� �1 2710 �, 7044,8usiness and Professions Code). � , � � � CONSTRUC7ION LGNDING AOENCY � ���,� .�7 0�i �� I hereby affirm �hat there is a consiruction lending ugency' � � �� for the performanre of ihe�rork for which this pe�mit is pERM1T FEE � � fS�b-Totall '�,� ' O�J.O�—H 2 � issued(Sec.3097,Civ.C.). - � � , LendePs Name PLAN CHECK�NG FEE (One-Fowth�Permit Feel . � Lender•s Address � . PERMIT�SSUING FEE � � , � . . � � f certtfy that I have read this applicatlon aod smte that the TOTAL FEE � I Q . " . nbove information is correct.I agrre to compiy with aIl County � � - " � orJinances and State laws�regulating EIecU(cal wiring, nnd � � � . � hereby outhorize representatives ot this County to enter upon - � ' . . _ i theab e-mentio ed property tor insp tion purposes. SEE'REVERSC FOR EXPLANATORY LANCUAGE at � •1—�i�—. SiBnature of Permitte Date - ' � . , � - , � — , ` . O«'\liF-IiUtLDEP.➢ECLAP ATION � _ � I hcret;y aftina U�at I am c�cmpt fcnm dic Convactor's . . .... . .�.._�.- qaPROVA�S ' DATE �N�'r'ec�ott's . . . . .. Licens�� I.a�c foc �Le. fullo��inp rcason(Sec�iort 7031.5. ' . - SiGPtATUR@ . .. ..fu�irtecs nr�d�Profescions Code�: Any �ity or cotmtp � �� � � . � �TEA1P..COI'JEF POLE- '- . . . � . . - �:�I�ii'fr reqvi�cs a perir�it fo co�zstrtrcl. altcr. ir,rPro��c. � � � � UNDERSLAE WOFlf' � , � i . � - ' � de+r:oLcl! nr rcpe:r m�y smrcture��z�iur ro its Lrn�a+uc, � - -- � � � elso reqr�irrs Ure c•plicent fur sxch ycnnit 10 filr�a � � ROUGHCONOUIT-\ p � ��((�p��, � . � � signed sratcrrrcnt fHct Le�[r fic<rssCd.yurr:rcnt tn fl;C ._ . . : , . ,��(�jY` � p'nusiwes of the Corrtra�tnr'� l.tccitse I,a«�/('hapte�9 WIRING ' , _ . , _ __ (cantmencirrg irith Sertion i000) of_Dirisimt 3 of Nte � _. . � FIXTURES . � - - � � �- . _ . � � • 13usinesc mic' �olersin+�r CodeJ or dint he is exempt ... �.. , . .� , f'OVJ[R{�UTH�RIZE�� ' .- � . . ... . "..... ��.. . ' ;' , , Jl;er<�fro���an.'71;C�6ac�s far the e♦lege•t!Pzent(>tir�n.;int' . . rim4�tron nf Sertior; 7031.5 L}'miy r.npliccnt fora pernrit _ - uTIL17V�Co.NOTP�ED ' � � . � SLbjecrs ffle apP�+�em(o a ci�'i(J)r�mlfy ojxot mnrr ihan �.. _. . �- . . � �. .. . - _., n �. _ � . , � -�Jircluu!:�rcdd011ars1S500f.: ... � - .- .. � - � fINAL... � ...�sG�2� 6sx.'t�at� . .. � � / ' � ��0 1,�.b��'ncr o(thc pro,crty�cill do thc���urA.and � � ' NDTFS ." � � ' � [hc stmcturc is not intcndcd o,�offcreS for salc..- . . . .. - . . .. . . . � /See. i0-1-1.1:¢�sin:ss and ProJrtsion.e Cude:� ,The Co++- � � � - ,. � -� . - trcrror's I,icrir.re l.a�r �locs nnt app%r to mr omr.cr of � . , , , prnpert}��oloo builds or i�nprores rGer<ron,artd ioAo does ._ .. ___ . � � . ' � . . : � .. - " ` tucA �do�.;.hin:o�e7j prorid<•d t/+ct sr7clt iinprUremrnls . . � . . � -"-cre not tq�euded br ofjercd for snle. ll, lro�cener. N�e. .— -- .�-_... � . . ' . . . - ,bui!dlua-nr iniprnrcrr;cru is sofd x�rdiin one��•cc� oj � c��rr.pL;io�r, t):� oivr�cr-Gui!der irilf l�arc d1e�burtle�+ . . . _ .. ' . ... - . . � � , nl prorir;r.rir7 he di:! not build or improrc fur thc , . . . . . . � F�urpox�n/'snlr.f � � � . � � 1 am eccmpt undcr Scc. � • _ _ . 13 R P.C.for tlii;rc�son � . . ndte - .. � _ '_ . 0c;nc: h 5.'�' t'.: -. . �. • . . . h . . . , . . . � . , . v .._, � ' . - - � -- _ .. . . . . � . . . . . . . ?��,� , - ' � _ _ .._ . � . � ' � � � '. , � --.. ''e--4 n` �.i . .. . _. .... . , . . . . . . . ., - . , , . . � . ��: ,.. . . � . . . ' � � � , , �