HomeMy WebLinkAbout1677A WORKERS`COMPENSATIQN DECLARATION �� ��8� APPLICATI4N FOR ELECTRICAL PERMIT� � `�
I hereby aHirm that I have a certiffmte of consent W self �'�' -
insure,ar a certifimte of Wo�kers'fompensa�ion knsurante, COUNTY OF LO5 ANGELES 6UILDfNG AND SAFETY �j
or p certified,copy thereof.(Sec 3800,Lab.L} �
Palicy�i��J j{S1�mpnny��_ . . . . _ . FORAPPLICANTTO_ALL_fN ��__.. _ __ JOB _____ .__._. _ .. __ .._...
.t,Q,y. Certified copy-�s here6y furnished-___ --. - - New ResidentiaF$Idgs.&Poo - -� - -�� .- {�E . �ADORE55 � ' •
I Yf �GBrtified eopy is filed with the eottmy h�ilding inspec- 7&2•Family.Sq.ff. s ♦ — S � � LOCALITY ' .
y!f -tiandepartmeoL - -�f�{'^' --- ���-� .M�I�i-familySq.FL . ___._ . ._ _. _..._ .__. ROS555_T,. __ ��
^�M���� ._�- /����` ... :.-kesidenfiaiSv✓imming-Roofs.-._. _._ .
._.-- -.....- ----.. __..
DaTe _(�[[[� AppficvM�. - . FlRMNAME
. ..-�CERtfF1CAT£OF ExEMPi14N fROKd�K2BKER5`:. . �MAft -
- Qutfets-Rec -_Light_Sw._ .
COMPENSAflQFf 1NSSIRANCf -._:..:.._ . AODRESS
•..:�. , first 26 __..
(Thls ssetion-naad nM fw comR►Nad if ilw worlc tnvalypd bY Totai No. . . . AdditionaF ---�- --.. �.._�.- C1TY.._.�.. _-..... ..7e1.�N - - 1
tha pwmlt IE fov are 6uedrQd dalfa�r(i}00)or Ivss.}
I certify ihat in the-�perfwmance of-:�he�work fm=wltich.rh�s _ ... . aPPtlfAtuTx - �
permit fa issued:�sFwN rtat emptoy any perscrn.ia any mQnner - - �
w-�as�to become su6ject ta ihe Wwkera�Gafnpensation tsaws. 4�ghting Fixrures , first 20 ADDRE55 -
. - ...... . . . . - . ...�.� . ..Total No. Addifional �
�� .. _ CITY Tel.No.
Date Qpplicnnt Fixed Appt;ances Not,Over 1 HP._ ._ .. . ��_. .
NO7ICE TO APPU�P,M. f(, afier making this Cerfiiicote of APPLKANT ° ^_ _
€xampr�on, yau iFwutd-6ecome s�bjec.€_ia Fce Ydorkers -. , Range._—Fteater___DW. __ - . _ .
Coinpensationprovislonsof�theiabarfade,�au�custiortk- - Overt -- ry - �� �
_D er�--_W.M.-_ -� ADDRESS�
( with comply-w+th.such prorisiaru ar-ihis.permit:shutE be.... .Tap _-FAU� —W.FF.-..�... - . �
F deemed revuked. _. ._ ..__ - - CITY '(�y� TeL Na. 5g1 E4Fi1
E � - . Hood.__Fan _Other.— _���QR
a ��--:��:-€fCENSEDC6NTRAG30R�;DEC{AiL431E3hI -�:=-.- Dis �RoomAir�Cond. — � Class.
_. f krereby affkm that f am(icensed under provisions of Chapier 9 P� � . � REG.NUMBER �Q L�$ -], .
(commencing-wiih Seciion 7000}of 6irFsion-3 o€-the-Business� DIStRICT NO. PRpCE55EE7 BY
and Prafesaions Code,and my license is in.full forcea�t-eHect. - Power AppwaWs&lnrge-App4fances� .. . J_ �
. . ���. �.... /.J"/t/ -Size-S Iype-HR,KW;KVA,or KVAR� l�� (}
�_ Litense N�rmber Lia Class�� Up ta E Incl. PINA1 . � �
. � C/L'��C�! Over 1 to 1Q Fncl. QA� ;p.2�-''�Y�+ _ . YAUOATIGN . Q
- Contractor<!� L Dale-�� - 6ver t0 to 50 Incl. . . .
FINAL {~j
�❑ 1'amexempt.urtdet.5ec. - ---- -. ..-_.-.- - __ ..._Over�56-to-WO�{nc.... BY � ' �W
_�:. . .._._.. ..____ ____- .___..___... ____.. . __
&.&F.0 for Mis reason ._____._____DUer SDO _._____.. ..._._.. ___._.._ _____..._ __ _.___._._._ ._ __.__..___._ ...__.:.� __.. ....____ _?_.
.. - .. . .. _. . __._..___ - Services,5wbd..MGG&-Ranelbowdc.. . ._ �_ . .
_pate: Q-2Q(}Amp.Under 400 V _ �
---��.$ignature_ - � - 201-IQ06 Amp.Under 6Q0 V �
-- . _._. .._._.___ .__.-------.__... . . _� - ---- .. _._._ __ . . . . ._._ . . .._... . . . . .
_ _
❑ � Over 1000 Amp.or Over 600 V . -
Exemption for Req Maint.Elecl. -
.SINGLE fAM1�Y Femp.Power Pole&Appurtenances - `� �'7'7 A
HOME OWNER-9UILDER DEELARATION Sign.vrifh 4ne Branch Cixwlt- � #. . ..• •�
f hereby aHirm that i am exempt from the fontractor's license ��4a�ona4 Sign&pnch Circuiis -
� law fortFse faltawing reoson(Sectian�031.5, Business and � - � - '
.Professkons Code}: � I • •��.J�� i
Misc.Condurt�&Cond�ctors
❑ I,as owner of the properry,will do the work and the � . .• ° m��.�3 C cS�. �
- structure is not intended or offered for wte(Section Other(See Complefe Pee_Schedule}_ � . �
7044,Business ond Prafessions Code). - . ._ _ _ Q�,z J�8 i
- CONSTRUCTION LENDING AGENCY . . ._ - - - -
t hereby_pffirm tFat there is a cortstruction Iendirrg ogency for - �
the performartce of the work for which ihis permit is issued - PERMIT PEE . (Sub-Total) . -
(Sec.3047,tiv.C.).� - � - �
. - PCAN.£HECKING FEE - . . �
Lendei s Name - � - -
PERMIT ISSUING fEE /.r0 � .
�Cender's Address � � . �
i certffy thqt 1 have read ihis applicotion ond state that tbe TQTAI FEE
above inforrrmtion�s cwred.I agree to comply with all County - �, - �
ordinnnces and Stnte Iaws regulating Electricol..wiring,and . - . �
hereby authorize representauves of ihis Coumy to emer upon - - �� � �
the ove-mentioned property for inspection purposes:" SEE REVERSE Ft3R EXPLAAIAFORY 1ANGUAGE
�:-�"�7��-8�'
_� Signotura of Permittee ... . - Date.. - . . -� . . . I
� ��V 2 dl d« �„Ci. N yl 0` m � V � V O O�� . _ .. .
. �."'_-= ` 'o ';�= a ca.'o` a ° `�+ „ c �,.'s'a
or"'o. 3 � $„op�a`m °jO � -�' o ° h `v �"c
� C C_C m_C y C 'u'� ,�t„�..S.0 0 .� U Q 0� y� O ' �
. p � C O 3 y m.G .
v° o ��+hmoe ° y > uai.co� c-� �-.
Z-: is 4 ? �C a 1 O C u�: � N 1+ �, p � G8 ��Oj .
.� ,��-40 ° � ° ° E m E°�� o =3 d� > y
• F= �a.�� o.o � oa-aa -o `om3 sc,. �
at E c E ti r. Oi��u��:p �'� ._ p p C O� ; o `n p . . .
�L Y= N Y .�n. +�- "Q`M� d � � .��V O p p_d b.,� �.� . .
�g N t d � ~ "' T 9r r'C„ �'` � m z r0, G� � `�,c,� .
a ¢= o E .c � d E �'�o .�,c m`a.
m °'�° ,. `m a e„ o.< a,_, a° „a m �^� "e�` aY
c oa� pomy� o� W.
',�" °' 3 ° � qu �V.MXoe � avoti a.?�� mw,-, ,
o Eoy'c ya3 � c� a•.. ° J+°c.°°' c° �� N�` L- �' o "
� o o c m �� p o C + ct� a..a r.3 �i° N � '
m — m ° 8.a..° a,"�= m $a o c y o .°a'°�s m � �
W,� r�m: ' ac�ieGpmau�i mom"a�o� „x ° "� y
Z E Q' M�= m"-�"e °'a, � � � 3 '- ,� y a �
�y .«°.o. � y�a��°� m ° ' 3 � y ° � a� � E "�
�,. o a,>.>-:o— o-+ o= o m a
� � 3 c Qo a.s�c`��c' a u� a mO° N y „ a m�= o � ,° • �
� ��
�'J .y, Na�.�°c��`oa.n�`'"';,� u`aE�° �-a� x 11
0 o v 2 r. .a °D � `o a�
° � c� m`c »'-. ° =�� ,.o�a �y Q.`cQ ,o � a � �
moa mcZ Leye— mm _cio � o-� a+ 3
s�m' �o 'v�Eu°��:� ��° f'�'.� 3 3 � E o c° ° m � O , "'
oWc
Q
Z
�
a
r
� �
a � �.� ,
� o
8'� � -
�
�
�
a g o � � ~
o W 3 z ' � Z '
oea �.r °° O � s O �
a S g � � a u
N x c� � � '
J N
� Z O � � � � Q �'
� o� 3 � � a � �