HomeMy WebLinkAbout1401A .,WORKERS'COMPENSATIONDECLARATION 7ense3 �o/e� qppLICATiON FOR ELECTRICAL PERMIT {�
I hereby alfirm that I have a certificate of consent to self insure, ce-soea
a a certiticate oF Workers'Compensation�nsurance,oi a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY u
copy�here f(Sea 3800.Lab`�.C.) �y
PoIiCy N0. � ��J,�mpary �N'OL��/KJ� FOR APPUCANT TO FILL IN � ' ' JOB �
❑ Certified copy is hereby turnished. . . . f��', New Residential Bldgs.8 Po�s�7�� EACH NO. FEE ADDRES � �J,♦ U �
�� Cer(ified copy is filed�with ihe county bulldirg inspeclion 1 8 2•Famiy,Sq.Ft._fJ_`__!__C(_ 5 = S LOCALITY ` � j � �
f� �. � MU�tI-femily Sq.FL NEAREST
/��n CROSS ST.
Date ��3�'�7 �. Applicanf '��Li� Residential Swimming PoolS owNE�OR
' . � FIRM NAME N
' CERTIFICATE OF EXEMPTION FROM WORKERS' i ' ' - MAt� �y �7
Outlets:Rec—Light_Sw.— � �� C
. � CAMPENSATION INSURANCE � � � ' ADDae55 -D• ...7�i� �
(Thfs seetbn need not be Completetl N the work Invdved by the First 20 r �-
permil Is for one hurWred dollare($100)w less.) . Total No. Additional CITY �/� Tel.N. ,�
� I certify ihat in the performance of the work tor which this permit ... PLAN C��ECK
is issuetl,I Shall not emplpy arry Person in arry manner so as to AP��M _
become subject to the Workers'Compensation Laws. � Lighting Fixtures First 20-- � � ADORESS - � �
� - Total No. Additional
Date Applicant � � CITY _ Tel.No.
Fixed Appliances Not Over 1 HP PERMIT
N0710E TO APPLICANT: II, after�making this Certificate of / I (� �.
F��-�—ation,you should become subjxt to lhe Workers'Compensation -._ Range_Heater_DW. _ 7��-iCAr'tT — /G
fons o1 the La6or Code,you must forthwith eomply with such Oven_Dryer_ W.M._ ADDRESS ,v. ��
�provisions or this permit shall be deemed revoked. � . . ..Top _FAU- _-W.H._ . . . .
� LICENSED CONTPACTORS DECIARATION Hood_Fan _ Other_ CITY � � Tel.No / ��j
I hereby aftirm that I am licensed under provisions of Chapter 9 � ��Disp.�—Room Air CoM. — uCENSE OR /►,,�' y� ck�
(commencinq with Section 7000)ot Division 3 of the Business and REG.NUMeER U v 0�7 ���
Professlons Code,and my license is in full force and eflect. oisimci No. PaOCESSED Bv
� Power Apparatus 8 Large Appliances � . ..
Size 8 Type HP,KW,KVA,or KVAR 1' �Q1 O O
_J,l __. . _
Lieense Number__�Lic.Class /v - Up to 1 Incl. FINAL - V
r�L�Z7�G-��Date /`-3 �� �r 1 to 101ntL. DATE `,Z J^ � VALIDATION 0
Contrxtor Over 10 to SO lrxl.
� FINAL V
I am ezempt under Sec. Over 50 to 700 Inc. gy
B.BP.C.for Ihis reason Over 100 G.
�
. Seivices,Swbd.,MCC 8 Parielbbards � - � � - z
Date: 0-200 Amp.Under 600 V
Signature � 201--1000 Amp.Under 600 V � �� �� q � A
❑ Over 10D0 Amp;or Over 600 V a
Exemption for Reg.Maint.Elect. �� � � � �2
� �� � - SINGLE FAMILY � �� .Temp.Povrer Pole&Appurtenances � • 1 2�1,4 6
HOME OWNER-B111L�ER DECLARATION Sign wi[h One Brench Circuit • /t�1 CFI,_
I hPreby affirm that I am e.empt trom the Contractor s License Law .AdAitional Sgn Branch Cira�its ����,V I U•
e fo!!owing rcason(SeCion 7031.5,Business and Prc!essions- �
� .
❑ I,as owner of the property,witl do the work and the structure Misc.Conduits&Conducto�s - - � ' ' �
is rrot intended or offered}or sale(Section 7044,Business . Other�See Compiete Fee Scheduie)_
and Professbns Code). , � � �
CONSTRUCTION LENDING AGENCY - � � � -
I hereby affirm that there is a construction lendirg agency for the / �
performance of the work for which this permR is issued(Sec.3097, PERMR FEE � (Sub-Total)� � � � � -
Civ.C.1.
PLAN CHECKING FEE ---� - - � � �-� �
Lender's Name //'
PERMIT ISSUING FEE � � y �
Lenders Address /� I�
I certity that I have read this appl�cation arW slate that ihe above TOTAL FEE_ .
inlormal'ron is correct.I agree to comply with all County ordinances
and State laws regulating Eledrical wiring,and hereby authorize ., , .
representatives of Ihis County to enter upon Ihe above-mentioned - �
prope'rty/�for inspection purpases. n
`_Ci' W1N ��+eCJ1 " 3 � SEE REVERSE FOR EXPLANATORY LANGUAGE . . . ..
Signature of Permittee Date �
. ' ...r. .. . .� . . .. :..�. � . . .
1 � �
� ,•�.
.. ' ' ` � ' , � ' i�
. . I . L'
_ . ' � ' • � t
, �
: • � .. . , .
' � ., , , ..
' ' .J • . . . ' . . . ' .
. . . - , . . .!I � � .
o T � p T � p z m
2
- � � � m c z c�i m � -
� ,- , - < 77: m� G) x � � a � -
C� D (!� � n � � -
� . � �. �: m � .
� O 0 1 � .p ; ,
_ . -r � - � O v �. : ..
. � T N. � Q � . .
� � � � z
, _ P.7 � � m •
i
�
- -- - - --- -- - - - - - �
_ . ,� � .. -- . .' _._ .�`.� ` p . I
�.,� i ^ �
_ � � �" Rl
i � C
j' i ; ' � ' . � .
.._ , . _; . i - '- �`f _ " . .
' 1
� � . . . ._. .. _" ' _ _ {
• �L .
; ' ' ' ' � J �'O � . .
- � � • �C) :
� � .. .. . . . _ ... .. _ �� , � ..
; mN .
� ,_ •
, ; ; i+ _i.
f - � -
' . , -., .,
. , _ ,
, 1 , . . : .
;
. c. .
• I V . '
i � . -
t : ,
._ j
�
. , . . � ���' r �
. . � , ,� . '4 , _
; .; , . , I./— _, . : . ' ; . I�..—•- .
' . , Q v W ,' � � o �� Cm� Q,�' � Q�, gm o`g=� �, _
� c��u �D '!3 . �n� �, � � � � � n�o �� "p $� y,0 $� `G fj� i
CJ , � �' _ Q W '?� q O� ❑ J Q n J � � �A 7pri O�- .
'' , . . � '��, .,O-. 7 � � (D At�i A� —Q " fp 5 V O N �.� g � �� .
. .. . . . O � , tr � _.y � A (n � ry �j>� O C �j „� � p „ ;� .
9 0
. .. . . 'o e S � � v� � p�^,' A � ..
, � e � a oo c+ o`� 3m..C' �.o3 �
. . =r � � � Q � `mo � � � _ �$ `g� � y 8 � �,'� o.�� `2
... . . � , �' � �. > > � 7 �� ' m � � N �'�' o:`• ' � ^' m r � .
� . � L'� p� a a o a„� a,�
C� . J R' -�i.,' � fD S n "� "�C 'N � �
.. . . � i � N '�..(n •- � Q y Q� gi n C� �`� � i^. � �E p n tV � pp
' . . i � '-o i �� c`o � � f' �,� n° m �,co � � � ° NQ�,,� o � c .
_ i `� Q F � o � o o�� a� m� �G��� � � � 3. � � ..
_ _ ' g °, g `° m4$ �� o < � � o � a,� �m ..
m �
, . . � . _• m �� � � o �g a� � m �m r� C)o� �� � o �p ' '
. � ' . _ � ,�,, g $ �.nc � Y z � � a ���i $�c � ..
. � � � m
: _
; . ; •. �a
' � , - � �' � c� H4� � no � � N� � �7r. �,� � � � �m r
N �. � O
-. ' ' ' . . ... .. . `Q�O � �a O O� _ 5 k Q�:�. ,, +(� � . � ..
.. . ' . .. � � � ? ? ' fSD ` O O� � �p O (�.,�:� �N � '
. `o�'�� � � t . r� W �' 3 � � ti c � �O'
.� � R_� � ° �. �,� � ���'.�•� � N Z'
..-� ;' . ./�' - � ��`� ��� � a. ' �� 4��o g .:,� °i � �_ . :
� `
i � � c, f � °�� '� �
. ..._ . .. ._ �£:n � R c� �c� m � � � m Q 3 n � _