HomeMy WebLinkAbout0876A �. NJORKERS'COMPENSA710NDECLARATION �,q�,3,e� qpp��CATtON FOR ELECTRICA! PERMIT �
� hereby affirm that I hove a certificate of consent to self ,�.�
i'nsure,or a certifimte of Workers'Compensation Insurance, CCIUNTY OF LOS ANGELES DEPT.OF PUBLIC WQRICS
or a cartiffed copy ihereof($ec,3800,Lab.C.) -
Policy No. Company iOR APPLIGNT TO FILL IN . �pg .
�Certified copy�is hereby fornished. New Residential Bldgs.8 Poois EACH N4. FEE ADDRE55
IQCHUTY
Ce�t7fied copy is fifed with the w�nty building inspx- 1&2-Fomity,Sq.Pt. s — b �
�tion department. Mulri-family Sq.Ft. � �ARE57
. Resideniial Swimming Pools ��u ST. Y✓jI`'
Da�e App{icanF OWNER OR
FIRM NAME
- CERTfFlCATE OF EXEMPTION PROM WORKERS' putlets:Rec�Light 3 Sw� 'W"��
� -- �CAMPENSATIONINSURANCE ADDRESS (,�G .v4` GJ
(Thit wclion twoA not 6t tomplabd iE tba work iavu{rvd by t, Firo6 20 CITY
� th�parm{t{s for ona hundrod dol{an{SIW)ar bss.j Tofal No.JJ� ,qddifiorw4 O�t.Y�/j/Jn.Tei.No.)/�J��/'� �
I certify}hat�ir�.he per4armance�of�ihe wwk for-which this PLANCHKK
APPLICAM
permit is issued,I shafl not employ eny person in ony menner
so as to becom�ed to the Wor ers Gompeototlan tows. Lighting Fixtures Pirst 20 ADDRESS �
..loksl No.� Additio�a! �
- ---. .__ __. -___-. CITY Tel.No.
6ote - -�. �- Applican ' . . . . . ..
� NOiICE TQ APPLICANT: If, aking this Cenificate of F&ed Applionces Not Qver 7 HP p€p�� —
Exemption, you should c subject to the Workers` � Range— Heater—D.W. _ ���n� � G �! ,.
Compensaiion pravisiorts o t e tabar Code,you must forth- Oven —Wyer —W.M._ qpQR� ¢� �����y �pU�
wifh comply_wifh such pcovisians ar tbis permit shall be Top �FAU —W.k.—
deemedrevoked.�- - � � � Hood —Fan —Other_ CIn f1�TeI.No. �,�_3�
��� LICENSEO CONTRRCTORS DECLARATION Li�NSE.OR.._.
i hereby nffirm thaf I am litensed under provisions oE Chapter 4 ��sp. _�Room Air Cond. _ . REG:NUMBER - - Ctass.
(commerrci�-wifh Settion T060)of Divisien 3 of the Business- power Appprptus&ldrge Appliances - DISTR{CT NO. f/ pRp{,E$�Q gy }
- andProfeuio�sCoda,arn{mylicenseisinfu!lfortearadaffect_ � Size&Fype HP,KW,KYA,ar KVAR � k � �
license Number ���'�-�J 7 Lic.Clau � Up to t lncL � fINAI U
Canfi�tor.`�r`�C ��'f�-note�..�. 9I . . Over 1 to iQ Ind. DA� _. ,�i- � VALIDATION �
❑ --- E7ver 10 to 50 Inct. . Q
t am exempt under Sec. Over SO to ip0 Int. gy�� �
B.&P.C.for this reason Over 100 ...__...._..- ..- a
Services,Swbd.,MCC&Panelboards � �
�+te: �
- - 0-240 Amp.Under 600 Y �
Signaturo � . - 2p1-IWOAmp.UnderGQOV
Q - - . Over 7000 Amp.or pver 600 V
Exemption for Reg.hM1ainl.EleU.
SWGLE FAMILX Temp.Power Pob&Appurtenances
HOME OWNER-BUILD€R DECLARATION u�� l.(7�;
-7 herebp pffirm thal l am exempt from the Cootractor's License Sign wifh One Branch Circuit
Law for the following reason(Sedion 70.?I.S, Business�and �4dditional Sign&anch Circuih #e ' • s e�
Professions Code}:
"�.1,as owner of the property, will do the work and the
Mitc.Conduits&Conductors 1 ' °���v'C
� strodure is not intended or offered for wle{Section 7044, Other(See Complete Fee Schedulej_ � � •• �c�f�l:l�a
� Business ond Pro€essions Code). . �
CONSfRUCTiON IENDING AGENCY Q�u� �"v ii
1 hereby offirm that there is a construttion lending agency for -
the performonce of tbe work for which this permit is issued PERMIT FEE (Sub-Total) ��j
(Sec.3097.Ci�..C.). . .
- . PLAN CHECKING FEE
Lende(s Name -. .:. . . .
- PERMtT lSSUING FEE �D
Lendei s Address
I tertify that 1 have read this apptication and state that the �fOTAt PEE � �
. above informatian is corcect.i.ogree�o cemply with all County - .
ordinances ond State laves regulating Electrica�wioing,and
hereby outhorize representa�ives of Ihis Caunty to enter upon
the abov -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�J P-�/Y
s� oore e,
»=o �
mor� w o+
0� � � p�� N T � .
N � .Q1�+0 C� .
O Y� O�� N �a �Q� �w� C O tU .
� � ���� Q�� � t�V d 9 v �i Q�.'Ci.. � N
'�jc �� a� Eo �"--n� � ac �� mnd3'�o
� �� E " �--
��m mNt o ��o °`w� $ar �''o�—co on��
,., G�a� �� � @ N �o �. w ci n� o mL. o '
N � V1 R
Uc� v°° o� � �,v, ��� �'i .ot� � 3�c�o
o m a c . � m d .c m
. � �e-�n c��c Y n m m�G c �� �.c w�
c w w an �n a o 3 a � m. G
� � �� �-? V,=� c�7= Or0 p v' C > � p
t Yd �i�_ � m � O -'— c`�' c `a o � C? N .
SL Q�� o Q u� 3 a� n+ e- c> 4 p �? m o o,,`�o � a' ,�t
� ��= m � m � � c ca m �p o avaF o N w
C m N U --�.r- 0 0{,� p � i11 O. T O �
U, y� N U � N N L M � @ C .: O m G O.'�S' (�U �N � C '(i' ..
w� d> y O N � 07 N C y(!l IXS _,�.� t0 �t1 y C C "', �+
�O X �..' L C? 0 �O U 8 G G N O N •�?yi O y a.
(L °' C�� V�-� �' aCn��'�' ��" `c� c m�db �' � �
�11 %' � m °�yu' '- Eo �"' p Gcu' oEB �'� E �
O m � c o o �o 0 o�c� o� `� m ''�n �' m m m s 6i C), y �i
,� �$4 E�� n o m o .y,ie to @ m�Y Q�, co c X� 0„ a O
ip " d c0 c�(/1�7 O
� sy�i m c°'^�is o'��.am'� Q v��>��y,� v � �
m }0.'_
� � N!6� N V G t0 tl.p . 2 R C �V 7i O � .
y �' 0 0 . N� �O� O c�n � . �N U c�.,i ��u1� U
�T wgN� �rn �onE� �J� _
� � '� y yocn �mp� p� .� �'
T m O C � lD C w Q Ky Q:�-
'�C,a U O 6y � a C7
- �N
t V � � ��
��J
N�y �
OC?
y�' �
�
� � �
� ' ° \
4 � d �
o � �
�
�s � ,
Y
� ct r S Z
j a p p � p
� � m .d S y �'� 4 0 ,\ .
o- o. � � Z �. �' � �" Z
Q. � � � � W � �
r � d �
� � ' �
� �. ,
� � �
� _ � �� �./"'
�
..--""