HomeMy WebLinkAbout1076A WORKERS'COMPENSATIONDECLARATION � 7ea663 �o�a, APPLICATION FOR ELECTRICAL PERMIT ,�,,x� 4rD j`�
I he�eby affirm fhof I have n certificate o1 consent to self �E"��
insure,or a certiflcate of Workers'Compensation Insu�once, COUNTY OF LOS ANGELES BUILDING AND SAPE Y � ��L�
or a tertified topy thereof(Set.3800,Lob.C.)
-rcyat�-��b�
P�oli[y No. ompon FOR APPUGNT t0 FILL IN � !OB . ` .
Certified co is hereb furnished. , EACH NO. FEE p�RE55
� PY Y New Restdentiol Bldgs.8 Fo Is —
1 8 2-Famil� Ft.�{�,� s — E IOCALITY
Certified copy is fited with the coun�y building Inspac- Y�SQ•
tion depor�ment. MuNi.{omily Sq.Ft. NEaREST
1- Residentiol$wimming Pools GROSS ST.
Do�e�.L��Applimm .. OWNER OR
FtRM NAME
CERTIFICA7E OF EXEMPTION FROM KERS' Outiers:Rec_Li9h�_Sw._ p�pD�REu
COMPENSATION INSURANCE First 20 ` �
(Tht���ction naad nof b�eomplet�d if 1he work involved by Totol No. -.� Additional CITY � Tel,No. -
fha parmit If For ona hundred dollan(SI00)or las�.) , -
I cerlify thot in the performance of thg work(or which this �N C�M�K �
permit is issved,I shoil not employ ony person in ony manner -
so as to become subjec�to the Workeri Compensation Laws, li9hting Fiztures First 20 ADDRESS �
- �- Addiiional
� _�/�/�y Cl q_D���y� � . Total No. CITY Tal.No.
pate��flpplicaN�i1�r ���•'s���/� Fized Appliances Nol Over 1 HP - PERMi�
� "�TICE TO APPLICANT: li, oker moking ihis Cerlifimfe of A���N 4
jmption, you should become subjec� �o the Workeri Range_Hea�er_D.W.._
'Compensa�ion provisions oi the lobor Code,you musr forrh• Oven _Oryer _W.M.�— ADDRESS �
wi�h�compty with such'provisions or ihis parmit shotl be iop _FAU _W.H.-- '
deemed revoked. CITY Tal.No:
Hood �Fan _Oiher_ �
� - LICENSED CONTRACTORS�ECIARAiION - uCENSE OR
I hereby oHirm tho�1 6m licensed under provisions of Chapter 9 Disp. _Room Air Cond. — ReG.NUMeER Clo .
(commencing wiih Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED�Y
ond Professions Code,ond my license is in full force ond eHec1. Power Apparaius 8 Large Applia�ces . . . A a
/�� � � Size�&Type HP,KW,KVA,or KVAR- l0 �,�lL[-s/�-� 0 '
License Number"L.l �'�� lic Class��� FINAL � � � V
Up to 1 Incl. r
1��_('i�„ � ' Over 1 to 101nc1. DATE lD �( � VALIDATION �
CoMmcfor � v�c-L. Dale�� Over 10�0 50 Ind. - - V
aFINAL
I om exempt�nder Set. Over 50 to 100 Int. BY � r u+
8.8P.C.for ihis reoson Over 100 - U� . Z
` � Dote: � ' Servicas,Swbd.,MCC 8 Panel6oards- . � . . .. .
0•400 Amp.Under 600 V
Signolure 201•1000 Amp.Under 600 V � � � -
� � Over 1000 Amp.or Over 6pp V " .g� Q'�(�A
EKemption for Reg.MainL Eled. �
SINGLE FAMILY Temp.Power Pole 8 Appunenancos . ' _ ���� � � �2
HOME OWNER-BUILDER DECLARATION Sign with One Bronch Circuit
}eby affirm�hm I am exempf irom�he Conhac�or's license Addiiionol Sign 0ranch Circuits � • ��7 9�
...,4 for�he following reoson(Section 7031.5, B�sinass and �
Professions CodeJ: -• �� �7.9�c=i
❑ I,as owner of ihe property,will do ihe work and the Misc.Condoils 8 CondvUors � � -- � -
struc�ure is nof iniended or offered for sale(Sedion Other(See Complete Fee Schedule)- ► O 1.� S-S Ll �
7044,Business and Professionz Code).
CONSTRUCTION IEN�ING AGENCY - � � - � � -
I here6y affi�m that ihere is a construdion lending agenty for
the per(ormance of the work for which this permil is issued PERMIT FEE � (Sub-To1ol) "'1 � � - � ' �-
(Set.3097,Civ.C.). � �
. PLAN CHECKING FEE � . - � -� ��� � . .
Lender's Nome � � '
PERMIi ISSUING FEE . Q
Lender's Address � � '� . .
I ceriify thot I hove read this opplicotion and state�har the TOTAL FEE . � . _
above infoimotion is correcl.I ogree lo comply wilh oll Counly
ordinonces and S�ate laws regulaiing Electrical wiring,and �
hereby oo�horize�epresentoiives of this County to enter upon �� ' -
the obove-mentioned property for inspection purposes. SEE REVERSf FOR EXPLANATORY LANGUAGE
�J� 0 A.i�J[^'K� - _o -
Signolure of Permiuee � Date .
. � , . .
�� ;-. " � ' . , , �. '�� ....
: � -' ' � .� � o a � ' .
' ." G' � G Z y �` O y� ' '
_. ' . - O Z � '�" p, G� n � �o
� O ,
�'_ - " V+ �- < q- u' Z t j0 Y
Z o � ° $ N ,--•'
. , o �,
� o �
' M .
?„ o
� q�
� m
o ,
}
' �
� N .
� i .
Z '
. q, .. .
. �. p .
m
. ,r � ��
. r Q, s ,�
. � w m yp m
' �' ` tn!1 3 G. G 7 ,��, O i
, v' O m Q
' � Q� O ���N'6 m �' � '� �
. ., � a0 0y� v p p,��,p Q Np p p^.'..•O � .
, , f f °n ° a 'v�m o�,o°.° av o.£ " �
'. o,£v W�c° :�..�c�N�^no-6c o a o�o��3 00� �
� (P 4 a,^O 4SC m�C O On ?�p � rtn ..-p' N ?0 LP
�. � G t' D � N O=^G lp � n C p �� � G
' , - Q O 'd � A '._p„C� O �0.p C y� �.:• 'O�a'y p��.w� n0 ?O p �
!Z p 'n N p p'.�p...O p' 7 7'. W'O X �.t. r O 0!l +'n p�� t'1�
� •� • m o `c m °� �i+ c� 0 �P �-v f�� m -?0
p p "p 3^ M p o 3 aN o, �3 �a4.c �"°c n.�o 'O .
. � � �v�N o <.v o Q?. •� v c, c.i in ��'=%`� � n � ,
�" 6.�' � � � 1 .f�.. fo 5 p m � �
� �. � .. � � S . 7 ° To.°:m � '" a-o-m ° �x �Q � yo �� fy� ..
' . N �^ � lD 4 �^ T N " O 4` O , � a �7'p?.��4„��O O ,Y
, _ p u+ � �'a n �'°v m o q �o� �.o `o " M,_`-'- � 3 -�
, . . � p 'n . •j-Q�� � u ��N O,� p � '� O�'�?...N.3p'� N 1 Q
� , 7 , ma�a ».� o.co �.t m3< ov�,°om� o ° � o Z,.
m �.z� 'o N 4., •,,,M ° 5 � Qa < � - n
" � . _ �Q.� o oC�p.% - 3'v.°3� 3 < ��i+ o � a �
�v 6 3�a n c � � ,
' ' N p � O'O '� p (L O p ?«n 7 4 Q m ��4.D K �O
_ _Q < oa.�.o, � 3 � oma3 0�
� �:o'� °`^ Qf � o's � � � °.°'°-�N °"'" of �Q . .
m � m o sv� o,_=° =T
..N t O•?� O T� � . �,C V+Q p T�tr�.N'
� Q '� O.'"�� �.. G � +.O� .�..�L.�p C�
. + , �tD o ff �, p�'O � F a� D N � ?1D
O 7 y` N ''
. , � ' � ' � O n" W N 4 ��� O' � , '/•
. . . �� lG 7 f+ „L f� ` //��/•
.. ' a W o o z
o' '
- , �^1 „ /�i-
, - ,/
, /�.