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HomeMy WebLinkAbout1817A (10) WORKERS'COMPENSAl10N�ECLARATION 76Asss �o,e, � APPLICATIOM' FOR ELECTRICAL PERMIT � I hereby�ffirm that 1 have a certificate of consent ro se�f insure, Ce-sosc or a certiticate ot workers'Comaensation tnsurance,or a certltied COUNTY OF LOS ANGELES 6UILDING AND SAFETY copy there f c.3900,Lab.C.) _ � ,E�".. /�✓�i.$`�L . . . _.. Policy No. Comparry FOR APPLICANT TO FILL IN �� - - - JOB .❑ �.Certified copy la here6y,furnished. ,-...;_ �, • New Resid'ential Bldgs.8��-7-��/ EACH NO. �- FEE- AooREss � � 0'V Q/C_ ��1-Certified�copy Is filed�with tlie� nty buildirg inspection �$2•Family,Sq.Ft.�_L y = � (�� LOCALIT �. � � r- ni. '. ..`. .: �J��� �� : MUltidamily Sq.Ft. ' CR055 S7 �00t0_�Applieant ' Residenlial Swimming Pools � � � Fi�M NnME � �L�v�.- O 4 � '�CEHTIFICATE OF EXEMPT70N FAOM VJORKERS ' . � but� �� � >-- �COMPENSATION WSURANCE� � .-• ��- ��ets:Rec—L'ght_Sw— .. � ppORe55 .�-- 33a (Thfa eectbn nxd rwt be completad it the work involved by the Flrst 20 permk Is lorone hundred doilars(5100)or leas.)� � . Total No. Additional - - - - CIT - �/�.9i70� Tel.No. �7�� �I ceriity-thal in the performanCe of the Work for�which this permit � , _._ . ._ .'. ._ _ . P�AN CHECK - � �- is issued,I shall rwt employ�arry person in arry manner so.as to , � APPLICANT., become subject to the YJorkers'Compensation Laws.. .,. L'ghtirg Fixtures Frst 20�-���-- ��- ADDRESS ������� - �- — .. . .. . . . , . r Adtlitional .' . .. . .-� � . . .. Total No. ..... CRY. - �.. .. ..�.:.. .. Tel.No. Date . . ..ADWicant �._. . ��.. . . ... - Fxed Appliances Not Over 1 HP PERMir C �T10E'.TO--•APPLICANT::If, after makirg this�Certificate oF ��'' �emqbn,you should become subjett to the Workers'Compensalron �-�� _.Range�Heater_ D.W. _ AP���A�T >�ovisions ef th=Lsber„Cede,yoU mi�st IOrthwith Mmply.with such Oven.._Oryer_W.h1._ � ADDRESS ,Provisions or ihis permit shall be deemed rewked..;.,. . ., ._. __ -TOP --�FAU� _-W.H._.. -'.._... ._ .. . � A f p„L . ..� �- - :LICENSED CONTRACTORS DECLARATION-:;� ; Hood_Fan _ Other_ CITY Nv� � �,e�.No. 9/��� I hereby�affirm�that.l em licensed under provisions of Chapter 9 - - . � uGENSEOH . ���) , � (Commencing wifh,Section 7000)of Division 3 of the Busine54 and -Disp. _Room Air Cond. �-_-- - -� � REG.NUMBER - ���. C G/ Pro�essions Code,and my license is in tull force�and effecC ppWpf AppefetuS 8 Lafge Appli2nCes--� -.- ._. DISTRICE NO. PflOCESSED BV � . . . . . . . _.._ . ,/�n . ....... �-9 Size 8 Type HP,KW,KVA,or KVAR O � '\,�\O 11 e License Number ��U�J L�.Class �� -. . �... . . .. UP to-1 Incl...._�...�... . ... .... . ... - .. . . FINAI - - . . - .. V ��y. � . ... Over t to 10 Incl. DATE � 1�(`� _ (� ContractorA���-fL Date � --- . . . . -. ... . � a .- -.. . . .vnuonnoN._. _. . Over 10 to 50 IncL Fl�� � .�..I am exempt untler Sec. ��� �-• ' �� "��� ° �- --- �Over 50 to-t001na. ... . .... . .. ... gy . ----.' .. .. � .._ . .._...._... yA B.SP.C.for this reason Over 700 � � � .._. '.. .._. . _ ._ __._�__._..--Dalei...- ----- .__ _Services,Swbd,MCC�8 Panel6oaids. ... _ ____-_-. --- . , .� . _..._ . _ . _ . �... . `t 8 1'7.a ? 0-200 Amp.UndOr 600 V � ._- ._..... Signature � �201-1000 Amp.UMer 600 V -�� `` - � ��' '- � �" � � -'- - ��-��'� --� #�e---�� r - . � � �-� � - ��- -�- -� -�- � - � � Over 1000 Amp.or Over 600 V - - ,- . ... _ _. ... _ ._. . . . __ .. . .._ _ . . Exemption for Reg.Maint.EleCt. "�"- �� - . " ���-' �' ����� C 1,U:��� � ,- __.. . __ .___._---_ . . .. . . . � SINGLE FAMILY ��� �� � _ 7emp.Power Pde&Appurtenances _ . .- - � �,:- ' -.-'. .__ . . . .. --. e e � G 1 �i._u. � HOME ONRJER-BUILDER OECLARATION ' Slgn with One Branch Circuit - �lereby zffirm that I am exempt from the Contrector's License Law .p�itional Sgn Branch-Cirwits�-� ��-- � - � -� ' � � �- - -�- � � p C- ?^, --ror the tollowing reason(Section 7031.5,Bustness and Protessions �-- . _ ..2 Code): - � ._ Misc.Corxiuifs 8 Conddofo�s _. .... _.__. _ . . . _. ... t- .. .. . . .._.'- -. _� . . ' ❑ I,as owner of the pmperty,will do the work and the structure Other(See Com lete Fee Schedule ' fs rrot intended or offered for sa�e(Section 7044,Business _- . P . _ _ �_— .. . . �_ . . ._ , and Professions Code). �� - � CONSTRUCTIONIENDINGAGENCY � . �� � --��-"-�� ����- --���--�- - �� --� - ' ' I hereby affirm that there is a construction lentlirg agency for the � � perfoimanee of the work tor which this permit is issued(Sec.3097. - pERMIT FEE' �� �� - �� �" � � (Sub-Totaq - /� G �� - ' � � � � - � � -- - , Civ.C.). . �- � ' � ' � PLAN CHECKING FEE._ . . . . . . .. _. . _.__ _ . . _. .. .. .� ._..__._ . .. . ._ _. _._ -.... ____... ..._ Lender's Name , , � �PERMIT ISSUING FEE � � -�� -_- � - -_� (� �--- --. .... . . ... ._ . . .... Lender's Address ' -�° I certity that I have read ihis apptication and state that the above � .TOTAL FEE .. . � .. ./,. C�� .. .. _ ,' �-'�" . _.. _ _.___ ._._ informa[ion(s correct.1 agres to comply with all County ordinances � � � . and State laws regulating Electrital wiring,and hereby authorize ..,_. ,. .__... . _. � representatives of this County to errter upon the above-mentioned - - � � � � P�!iery/�(or Inspection purposes. � ' y�l(�/N 0�����/� ����i"6 �_. . . . .5EE REVERSE FOR EXPLANATORV LANGUAGE.. . _. . . .._ ... _ . _._ __ . ... S�gnature ot Permittee Dafe - ,t,;..? ' ' �,." . �— .� I:�`_ __._. . ,,U: , .i �: . . � � �. ..� _ i- - � ;'`i��,, i•__-•__T_-�..._; . . . �� ���•� I � 1 I I�1� , � I 1 �1 � , .: i �; ' � I A J . �i - ��J E, ��,, i , � �'; : ; :..-�'; ! � i e` .� �%I: I � �/.• I �� .. I r . . . . �� I� � i. ,I � I , ,� � �' ,��: �� !�Ci