HomeMy WebLinkAbout1326A (7) WORKERS'GOMPENSATIONDECIARATION 76A667 lOiBi APPLI�ATION FOR ELECTRICAL PERMIT �
I heieby affirm �hor I hove a cerrifico�e of consenf 10 self CE-806G ,
ins�re,or a cerrificaie of Workeri Compensaiion Insurance, COUNTY OF LOS ANGEIE$ BUILDING AND SAFETY
�or a certifie p+�py�,h�e'�r`eo�f J(Sec.3800,Lab.C.)�1
P❑olity N .__����Compony- ��[JL_ fOR A►PIICANT TO Flll IN qppRE55 �;a �5. _ -�, �
Ceriified copy is hereby furnished. New Res�deniiol Bldgs.8 Pools EACH NO. FEE
�� Ceriified copy is filed wiih the tounty building inspec- �&2•Family,Sq.Ft 5 = S LOCALITY L� '
li n epa�ment. Multi-family Sq.FL NEARE51 .
� /���. ,,_,�7 CRO55 Si.
Date �V{ Applicant � //1`LiCS [=/L�Z�Z/ Residential Swimming Pools OWNER pR
, FIRM NAME /1I.
' CERTIFICAiE OF EXEMPTION FROM WORKERS' O��lets:Rec_Light_Sw._ ��� �'i „�_ ��
- - COMPENSATION INSURANCE F.5'� ADDRE55
(TAIt��eNon ns�d nol b�tomplN�d il th�work inrolv�d 6y To�al No. Addi�ionol CITY � TeI.No -3,
1he permit is for one hv�drod dollars(5100)or I�ss.)' Rnrl CnECK
'I certify Ihat in 1he perfo�mance of Ihe work for whith�his APPtIC4Ni
— permif is issued,I sholl not employ ony person in ony manner —
so as 10 become subject to Ihe Workari Compensalion Lows. Lighling Fixlures First 20 ADDRESS
-� � To�al No. Additional
Date epplicant � CITY Tel.No.
Fixed Appiiances Nal Ove�1 HP PERMIT
N/ �i TO APPIICANT: If, oher making this Cerrifimte of A7PlICANT � � � � c�/G
Ez. �1ion, you sho�ld betome s�bject to the Workeri . Range_Heaier_D.W._
Compensof�on provisions of the lobor Code,yoo must forth- Oven _Qryer _W.M.— ADDRESS � fJf�
with comply wilh such provisians or this permit sholl be Top _FAU —W.H.—
deemed revoked. . � - CITY �N � Tel.No.�(p f�j
. LICENSE�CONTRACTORS DECtARATION� � � Hood _Fan _Other_
Disp. _Roam Air Cond. — ���N�� ��� Clos ��J
I he�eby oHirm thol I om licensed under provisions of Chopfer 9 REG.NUMBER �
(tommenting wirh Section 7000)ot Division 3 of the Business DISTRICT NO.�Q � PROCES$Ep BY U.
Power Apparotus 8(orge Applionces
_ and Professions Code,and my license is in f�ll forte and effec�. �(\(\\\,�" (�
$iza&Type HP,KW,KVA,or KVAR \� \lJ��+-�.�-
License Number ��� Lit.Clasps � Up to 1 Intl. FINAL �
rJ�`�,/�[IC/�}'�� o�a Over 1 ro 10 Ind. DATE YALIDATION O
Comrodo��� Dale W
OOver 10 to 50 Incl. FINAL .
I am exemp�under Set. Over 50 to 100 Inc. BY �-
N
B.BP.C.for�his reason �Ve'�� Z
� � Date: Services,Swbd.,MCC 8 Ponelboords � �
0-2(!0 Amp.Under 600 V
Signature � 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 60p V
Exempiion for Reg.Mainl.Elect.
� � - SINGLE FAMILY Temp.Power Pole 8 Appurtenonces � �=� 3 2 6 A
HOME OWNER-BUIIDER DECLARATION Sign wi�h One Branch Circuit �� � � � �2
S �by affirm that I om e.empt from the CoMracior's license qdditional Sign Branch Circuits
ldw for 1he iollowing reason(Seclion 7031.5,Business and ' • �6 Q .Jr O
Professions Code�:
� Misc.Conduits 8 Conduclors a o e 6 f),5 0=
I,os owner of the property,will do the work and the �
structure is not intended or oHered for svle(Sectivn Other(See Complete Fae Schedule�_ , � 0&2 6�8 6
70a4,Business and Professions Code). � �
CONSTRUCTION LENDING AGENCY V -
I hereby aifi�m�ha�ihe�e is a conshuction lending agency for �
the periormonce of the work for whith�his perm�l is issued PERMIi FEE (Sub•To�al)
(Sec.3097,Civ.C.). �
� PLAN CHECKING FEE � � � �
Lendeis Nome a -
• � PERMIi ISSUWG FEE -
Lender's Address .N� .
I te�fify thot I hove read Ihis application and stole thol�he TOTAI FEE �
obove information is mrred.I agree to comply with all Counfy
ordinontes and Sate laws regula�inq Electrical wiring,and , . , . .
hereby autho�ize represen�a�ives of this Coon�y to en�er opon , ��
�th bove-meNioned property forinspeclion urpose.
� ���Q �a� SEE REVERSE POR ERPLANATORY tANGUAGE
$ignoture of Pe�mittee Date
, •` /.
�,
� � . � • . . • � ,..
. . ' `' `\ . � .
. ` � - . . � � � •�'�'p Q �O" q • ...
� R, ��j .
. ,. . T O G� Z � � O tV
• . zp" p � p u, .4�. ,nO �'rn zi G
- cf� � r • 2 �z ;a q .
O Z a O O N
. . - 'O � � � m
� •
�
, =r �
.. �� � d .
� 1
p �.-1
�. r„
, � ' .
�
�.
o. .
� �
i <,n i
?
�
' '` , � . p7�. . .
. `` m
� ,
. � � ,
i � , .. . • �
,\ ,
,; . ,
� �� . ' , , �;
� ` ' . . ' . . , � � - ' ' 'k
' �\ . ' . ' ... , " ,. .,
. ` '� " . . . - . . .
.• ,� r� - .
.. , , . - ' , . . .. •. '•, p a`6 � �o � �. .
�'i � N N n� G n .
o v �4 7� 6 �
; �� . _. ' . ' � ' � 'ap'O�,.���a,9,-o u,� "C -•
' I� ' in's o =�' ,.� �o �T=, n a 4,Q. .� .
'� _ - . 4 f o m ° o ir a o -r o p n-o o.
\ �� . _ • � � ' • .= p S y1 n i�Q N ...�0 a' tl-O', _'O ' C7 -p � .� .
� \ i �. . ' i- � 4.'30.ttl �� �J G O�+C G �O M o ro-t"�3 �O� .- �.� . ..
� p � � o'.i �y,��' a�i+ O a p �� � ? �p � �
'c � � '� . � � � . �6 p< m?�q a`� A+o�'.��p�-. p ^ p ~ v� m� ,� • . .
• , � �V' • � c. du.3wv� wv•.o<-tm AF+ s�'p � . � G
'O CJ Q? M'N o G .O ' '�Q O-A �I,�` ? C � � O O t�
0 m . ,� • ,� _o� �a �o p N ?;.. o b m z v° o °w� N 3. 4 _
� \_ , . C `` ,'" ! .3. -, m �•� ^•�u�� �, �.�� O o p 9 G Zy~'~' 0� m �p' . � "
� . � . � 9 �� 'f r G <'30 p�` ��", K' �.."D p� �� 7 2 m��� �:n .
O
'. � �R ' • ' ' • S, �� �' 7 Ct-0.S < N Cl.�y P . �...0 j �" p ?� � �,O� ^�'� . .
.. ' . ' r �' . 0 O O �.''v' dN� '06 'p � O . 4 . 'p?..3 �. t! K� "" A .
. . - . e0 ' �' 9 04 , o �^ ; �. w b o .�� .
. - - . . � - . . ' • O �l(J� i�. �.� �S p � �9"� N 7 fi . O �n•� r 7 3 �
N e o 5 m mv M c�' . 9 '� a mo �.O. 3 .c O.
' � " � � . . . ' � �� . � , 7 �,n '"C c3'.o �.��'��p�'Z�, ° � < �Y,�o -C9 0 0 o Z
-• • �-o = c'�.z� o N�^ 4`. t0 �° � ��°o o ° � = n • ' �
`o o_
, , . �1 . .�? � £ 3_Q ' oaa Q�o3 N.3 N�Q.�o� ' J
' • � �° o o c.,°£�° o , �„^� � �� o W o " "� �o p. .
. . . . . . '.., ' � Q...� �� n £ B 0 P . O N � 4 �� u' �p O j��-'O � r
' ' . . ' . . . . .N G O•?3 O � S� f . S Q V�� 'O f0 O 0 N n tn N
` - �'� °5 3 � � a°`� ,/� � o � °'° f 3 q o s s•
- . . . . ' ' . .. ,n' ta'O VC N t4'O C�! �"O O �= N S m
� ` . . . � �@+ O N O ? ��� � �. 7 M
' " � � � tD N N '� d
� . ..' ' . - ' . . � T�� W '� n ~ O 4
' . ' ' . . .. 6.?O �?�
t1. . � � . .. • . . . .. . ., d 6
' � ^ I .
/
. .. . � . .. ��..
�\