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HomeMy WebLinkAbout1810A WORKERS'COMPENSA770NDECLARATION 76A883 ,o�a, qppLICATION FOR ELECTRICAL PERMIT /// \ I hereby aRirm that I have e certHicate of consent to self insure, CE-soso � � or a certiticate ot Workers'CompensaCron Insurance,or e cercitied COUNTY OF LOS ANGELES BUILDING AND SAFET copy the �(��cG.38�0�0,t7ab.C.) �iI� . PoIiCy N�Comparry 1'�-5�C/� FOR APPLICANT TO Fl�L IN-�- JOB -�'�f .❑ . Certified cop is here furnished, � EACH NO. �E AD�RESS S NTHc,ir K Y bY . � New Residentiat Bidgs.8 Po � � . � 1 8 2-Family.Sq.Ft.�77� � . — S LOCALITY a �. �� �Certitied�copy is filed with ihe county building inspection rime L � � Multi•family Sq.FL NEAREsi (�' CROSS Si. Date� 'v ApP��cant Residentiai Swimming Pools OWNER OR � . . . _ . FIRM NAME � - ��CERTIFlCATE OF EXEMPTION FROM WORKERS ' MAi� � Outlets:Rec_Light_Sw.— - - - -- , COMPENSATION INSURANCE . � ADDReSs _ . X �(This sectbn need not be completed if the work invoived by the First 20 .permit Is for one hundred doltara($100)or less.) - Total No. Addiiional � - ��TY �t,/a„9�"�„�,Tel.N PLAN CHECK I certify that in the performance of the work for which this permit - �- - � ppp���qryT- - - - � Is issued,I shall not employ arry person in any manner so as to � become subject to the N/orkers'Compensation La.vs. l'ghting Fiztures First 20 � ADDRESS ��- — � - ' Total No. �ditional CITY � � Tel.No. Date Applican� Fixed Appliances Not Over 1 HP pE17M1T .N`-' E TO APPLICANT: if,.after making.this Certificate of //��� � �CZ�� Range_Heater_D.W. _ ����M ion,you should become wbject to the Nbrkers Compensation . � provisions of the La6or Code.you must forlMvith comply with such Oven_ Dryer_ W.M._ AD�RESS �i ��� provisions or ihis permit shall 6e deemed revoked. . Top _ FAII _ W.H._ /I n p/�y� oYQ/ i/_ . � LICENSED CONTRACTORS DECLARATION - � qTY �,,�� � Q Tel.NpJ/ y�p Hood_ Fan _ Other_ I hereby alfirm that I am licensed Undef provi5ions of Chapter 9 DiSp. —.Room Air Cond. _ qEGNNU BER � � ����� (commencing with Section 7000)oF Division 3 of the Business and �Protessions Code,and rtry license is in fuil fOroe and effect. � ppwyf Apparatus&Large Appliances DiSTpiCT NO. PROCESSED 9v � ,�7�a /O Size&Type HP,KW,KVA,or KVAR � �O �•�0.�0 A Q Ltcense Number ���� �•� Lic.Class �r Up to 1 tncl. ' FlNAL p �� Contractoi{=/�-r��"" — Date �u Over 1 to 101nc1. DA� 3�3'p VALIDATION , � Over 10 to 50 Incl. V FINAL " ❑ I am exempt under Sea Over 50 to_700 Inc. BY .. . .._ _ . ... W � � � � - Over 100 �' 6.8P.C.tor this reason � tq Services,Swbd.;MCC&Panelboards � � - � - - -� � - � � Z - Date: 0-200 Amp.U�er 600 V Signature - 201-1000 Amp.Under 600 V - - . - . .- `�.��'�h ❑- - - Over 1000 Amp.or Over 600 V #• • • � •2 Exemption for Feg.MainL Eleet. � SMGLE FAM�LY Temp.Power Pole 8 Appurtenances . � • 1 2 l 4 6 l HOME OWNER-BUILDER DECLARaT10N � �Sign with One Branch Circuit � � s ,by aHirm that I am eaempt from the Contrac�or's License Law Additional Sgn Branch Circuits ° � C�'4��' �t�_�(�e following reason(Section 7031.5,Business and Professions � - - - �-� - �� � -- � coeeJ: 0 9.2 2—8 8 ❑ I,as owner of the property,will do the work arid the structu2 Misa Conduits&Conductors - � - - � � is rroi inteMed or alferetl for saie�Sedion 7044,Business Other(See Complete Fee Schedule)_ , and Professions Code). �-� - ��� ��� CONSTRtJCTION LENDWG AGENCY � � � - - � - � I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097, pERM1T FEE �- � (Su6dotap ./�Q - �- � � - - Civ.C.�. . � . PLAN CHECKMG FEE .. . .._ _ . _ _. .. _ ._ . . . . . . Lender's Name PERMR ISSUMG FEE � . .. _ __ . . - - - - - . _ _. _. LeMers Address I certify thai I have read this applicaYan ard state that the above_ 7YlTAL FEE - �� Infamation fs wrrect.I agree to comply with atl County ordinances . and State laws regulating Electrical wiring,and hereby authorize . _ � representatives of this Counry to enter upon the above-mentioned�- � - � �- � - �� � � � �� �� � � � �� - . m or inspection purpose///� . SEE REVERSE FOR EXPLANATORY LANGUAGE . . . . . . . .-. � �c..) � Signature of Permittea Date . '.. .. � . .' . , .. ...�.:s� :: . e ,. _.` ' - -� - -i--- — - '-r .. --. _ __. . ;�r ;i i, , .( , i ! - - ' - t /� �/_ i I , , i i `` ' { , . . `� + �1 / ' 1 I� ' r �,' �'!j'f I . . ` �/ , , . ,`. _I, ✓ . . . .i I_ ,i 1 �� � ' i �` � �-,/. ,i�{.l �;i�, ` , 1 , . � � � � It�` ' /I, _ _ t • . �. ^ ' ' i � .. ( � _ . . . i_ - _ 'l. , ,`. �-.__ . .. i Z T � O -�� {. .O Z � � .. . 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