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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATION DECLARATION 76A663 �Olet AppLICATION FOR ELECTRICAL PERMIT . � I I heretiy alfirm that I have a certificate ol consent to self insure, CE-906G or a certificate ot Workers'Compensatwn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY COpy thereof�Sec.3800,L2b.C.) � PolicyN��qO�B3�Company����T��pL �v� FORAPPUCANTTOFlLLIN ' "- - - .- �B � bq � SUV�1'� IJ��� � � EACH NO. -FEE Aooaess Certifred copy is hercby turnished. New Residential Bldgs.8 .�� . . � . . i d 2-FamilY,Sq.Ft.� S O _ `� LOCAU7 (�..�a S�(p'V �OT: cert�r�ed covv is filed with the cwnty building inspection NEAFEST �department. � � � a�..y)�� Multi-fzmily Sq.Ft. caoss si. ��` ' Date� 3o Applicant�� �01� Residentiat Swimming Pools . owNER oR flRM NAME�Ra��i� c-� . CERTIFICATE OF EXEMPTION FROM WORKERS' putlets:Rec—Light—Sw._ � � . , . . . . CAMPENSATIONMSURANCE,. �� �.. � �� - � - � - AODRESS 3� I � C �/ (Thic sec8on need not be compleled H tbe work involved by the First 20 • Tolal No. Additionat _ qTY �6� Tet.No.�`�-�DO permit Is fo�ona hundred dollars($100)or less.) . . . � . . . PLNa GHECK � I certify.thal in the pertormanca of the work for which this permit ��� - -��- �-- -�;- � �-- ppp��C.4N7-� � -��- - .is issued,I shall not employ any person in any manner so as to - _ � - � — hecome subject to the VJorkers Compensetion Lavrs. Lightirg Fictures First 20� -- - � ADDRESS� -� -- -��� . . .� � . ..,. .. AddiYronal ...,... Tel.No. .. . . .. , .. �. Total No. CITY .�. .... -_.. . __ � Date ' Applicant � Fixed Appliances NOt Over 1 HP pEaraiT �� NOTICE.TO-APPUCANT:.If,.alter.making�lhis Certifica[e of � ppp�iCnM � �� C�C�T��L Exemption,you shouid become subject to ihe Workers'CompensaCan Rarge_Heater_D.W. _ __ _ . __ provisions of the La6or Code,you must fortfivrith compy with such Oven—Dryer_W.M._ ADDRESS�r� provisions or this permit shall be deemed revoked. . Top ,_FAU _ W.H._ . . L. I`6y 6 . �� � . CITY^� � 0 1�U�`- -�7e1.No.J � _LICENSED CON'fRACTOFS DECLARATION . Hood_Fan� _ Other_ � .I he2by atfirm ihat I am licensed under,provi5i0nS o1 Chapter 9 uCENSEOR p ��$ - -- Disp. —Ro0n1 Aif COnd. _ {�G.NUMBER'L �� 0 ' 6 (commenCing with Section 7000)01 Division 3 of[he 8usiness and � Protessions Code;and my license is in full torCe and effect: power ApparatUs&Large Appliances DISTAIGr NO. PROCESSED 9Y ._ . _ . .._ _ _ ._..__.__.___ _/'`. . . . . ....... � ,Ip p, Size&Type HP,KW,KV0.or!(VAR v a O�'� License Number `1 1�_�6 3 LiC.Class �-t 0 . . - . . ._� ..Up to 1 Incl. ....`. . . .--._".. _:. ." ." FlNAt-. .. .. . . ... . V � . ,,�� �q� Over 1 to 10 Incl. DATE ��/� yAUDATON � � Contractor.�Ff*���� .� - Date��L�L... . " .�..Over 10 to 50 Incl.. . .. . . . .. . .. .. . .� U �. ❑ � � . . RNAL . . I am exempt under Sec. Over 50 to t001nc. BY . _._ . . . .. y� ...-. -. . . - � Over 100 p+. B.&P.C.tor[his reason !n Services,Swbd.,MCC&Paneiboards -.. ..- . . ----. _. �. . .... . . . ... . ... . . � ... _.__.._.. .. ._. - .__..__ Date:..___..._ . 0-200 Amp.UrMer 600 V � s�9�a���e zo�-i000 nmv.u���soo v �j 1 g.3 A 1 -� �- -- - - - - - � Over_1000 Amp.or Over 600 V � ! ExemOtion for Re9.Maint.Elect. • - .- .. .---. - . . ... . _ ..- . . ... .�r 2�� ' e e e e e � --- �- '� SINGLE FAMILY � -��- - � Temp.Power Pole 8 Appudenances , . � HOME OWNER-BUIL�ER DECLARATION Sign with One Branch Cvcurt � •�-� 2-�-4 6 I hereby affirm that I am ezempt from ihe Contmc[ors License law p�ddional Sgn Branch Cvaits _ __ .._.__. . . .. . e.- tor the(oilowing reasOn(Section 7031.5,Bosiness and Prolessions - - - -�� o � C��1(�•,�_, . °odej: 0&26-8& ❑ -- �Misa CoMuits&Conductors .. . --- - -. .- - .. . .. . . I,as owner of ihe property,will do ihe wak and the structure Other�See Complete Fee Schedute)_ � � is not intended or oflered for sale(Sec[ion 7044,Business � . . . 2nti Protessions Code6 . � ... . . . .. .. _ _ ._ .. . _._. _.. ._. . . .. . . CONSTRUCTION LENDING AGENCY - � � - - - �-� � �� �-�-- - � �' - -�'-� � � I hereby affirm thaf there is a construction lerding agency for the � - performance of the work for which this permit is issuetl(Sec.3097, pERMR FEE � - �� --��- �� ��-- (�b•Totap S � -�- �------ - �� �� ��� - �- � � - - Civ.C.l. � . � ._ PLAN CHECKING FEE - -. ._ . .---- - .. _ . ._ . ...._ ... . . . - _ - . Lender's Name pERMR ISSUING FEE . ... _-._._._____. ...-�� cs - . .. . . . _ _. . _ . ... - - -..__. .._.. Lender's Address n�� L// I eertify that I have read this application and state that the above TOTAL FEE �� 7p _... , . . .. .. _ _ ...._._.. . __. . . . . _.._ _ _ .._. . . ..... _, . . _ . intormation is correct.I agree to comply with aIi County ordinances , � and State laws regulating Elechical wiring,ard hereby authorize _., . __ . . _____..____.. ... _. ._ ._ _ .. . . . ._ _. � . representatives of this CouMy to enter upon the above-mentioned - � prop ty for inspection purp es. _ SEE REVERSE FOR EXPLANATORY LANGUAGE .. _ .. . .__. ._. ._._ _ . . ._.. . . . . . �� a� Signature of Permittee D te � � � ' � _ •�F�!:! _...�f:._ r�_� . . �'--:f , �— _ _f� _� _� .I--; _I_ _�. .�...__.,I_y_i...I�_—� � i �- - i� � ` I_ ..._�._ �, � i ;� � ,, _ � ; _ ; � I -- ; I I;� ;: ; _ � i _ I'� , � i" ,, ( 1�� : ` � I ; � i i. � - ! � i'' � (�' � ^ � � � � �.. � _ 1 � - "� I _i I � � f � . . "; { , , f I �� r _ � � • i � 1 • _ � ', i_ I i i I I I I. 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