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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECLARATION 76A663 +o�e+ qppLICATION FOR ELECTRICAL�PERMIT � � 1 hereby atfirm ihat I hava a certificate of consent to self inswe, � CE-Bo6G or a certilicate of wakers'CompensaCron Insurence,or a certified • COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) Po,;cvN�('_,]'.9o1S36'�mpy���a1S�R�A�. t�� FORAPPLICANTTOFlLLIN-' .� ( S �� (1 � � ❑ ,Certilied copy is hereby furnished. . , _,� . New Residenlial 61d9s.8�o�qq EACH. NO. FEE �oaESs � 1&2-Family,Sq.Ft.� 5� — S - LOCALITY.� S/6 V . �OT� � Certified�copy is filed with the ewnty twiiding inspection _ NEAREST � �department.' �� Multi-family Sq,FR CRO55 ST. -� ' � � ����..`� Residential Swimming Poois Date� 30 � �� Applicanl � FRMNAME '(Y\�. r � �:CERTIFICATE OF EXEMPTION FROM WORKERS' �. ..� � �.�. nwL [� �1,h � COMPENSATION INSURANCE . � , OUtlets:ReC_L'ght—Sw.— � ' AppqESS�I,], . VC. N . . . _ . _ .. . .; . .. Thb settlon need not be com letad It the work Involved b the Frst 20 ( P Y Total No. Additional� CIT �' Tel.No. SO� OO � permil is for ono hundred do�lars($100)or less.) � . � - - I certify.that in the performance of the work for which ihis pe�mit ' - � - . �p���NT K . _ is issued,I shall not emp!oy arry person in any manner so as to � � . _ become subject to lhe Wo�kers'Compensation Laws. L'ghtirg Fixtures Frst 20 � - � AD�RESS�� � - � � . . � Total No. . Additional... . . .. . , '� CITY --. ---- -.. .. . TH.No. Date Applicant Fixed Appliances Not Over 1 HP �NOT10E-TO APPLICANT:� IF, afler making-�this�Certificate of PERMiT � C �\C` �lC ,Exemption,you should become suhject to the Workers'Compensation Rarge_Heater_ D.W. _ � ���M � ^.••.^��^ �^�_�^•GM_e�)^u mv�!f^rtlr.•�i!h coro;!. �., � . ._ . �' - . . _. .._ .. . .. AD�RE55 _._ns ef L._ /••.,!!h_,:^h O�pn_ Lkyer_ W.M._ .�.^. .6 - ,.._.. _ , .provisions or ihis permit shall be deemed revoked. ,__Top _FAU__ W.H.___ . � .LICENSED CONTF2ACTORS�ECLARATION� ��, Hood— Fan — Other— ��T� O � O �- Tet.No.�'-�j��Ej' .I..hereby aifirm thaf I am licensed under provisions of Chapter 9 ... Disp.-_ Room Air Cord:--�� ._ , uCENSE OR p, . Class./� ��(commencirg with Section 7000)of Division 3 of the Business and REG.NUMBER" ��'p l.:`� � Professions Gode,and my license is in full foroe and eHect � oiSmiCT No. PaOCeSSEo er .. Povrer Apparatus&Large Appiiances . . .___ ._ , . ,/��� t .. �-' ,'�y p,�7 Size 8 Type HP,KW,KUA,or KVAR � �G t+ \Q\cyri� �"5.rC, - License Number� l��O J Lic.Class �-'U .. .. -.UP to��1 Incl. .". . . FINAC- � ..��-_f.�.... --- ... .. . .- . � . V �I�C�"I�.l C A L� �Date� ...�. . _.. ... ...Over i to i o i�i. oAre L—5%O' - . _� . VALIDATION .- - � �. -Contractor Over 10 to 5D Incl. FINAL F""' ❑ I am exempt under Sea �-� . ,_._ Over 50 to 1DO Inc. gy /+ w . . . . . .... Over 700 �� ...- .'. ' . p. B.BP.C.tor this reason � � - Services,Swbd.;MCC 8 Panelboards� � -�-- � � - � _... _... . _. . _. . ozre: -- - -- o-2oa n�m.u�de.soo v �1 1 8 4 A "` Signature �-���207�-7000 Amp.lJndcr600 V --- --�� - - - � -�' � - � -�- � � � - - � - .❑ . . _.. _ .- . _ --_ � Over 1000 AmP.or Over 600 V. _. __. . .. . . .. .�• • • e •2 Exemption for Reg.Maint.Eled. -��� -� -�-- -- � . � . . _. . . _ . . ..._ . . . � �-- - � ��-� --SINGLE FAMILY---� � �-- � Temp.Power Pole&Appurtenances � ° 1 2 C�4 6 HOME OWNER-BUILDER DECLARATION ' - ---- - ---" -�- �- --' � ��" �� ' � "-""� "-� - -�-" �� � I hereby alfirm that I zm exempt from lhe Contractor's License Law Sign with One Brench Circuit � ' • • � 2�4 b�� for the fvllowing reason(Section 7031.5,Business and Professions � .�ditional Sgn 8ranch Circuits..... . . _ ._ code): _ 0&2 6-8 8 � � Misc.Conduits&Conducrore� -- � - �� � �-- � � - � �- - I,as awner of the property,will do the work and the structure is not interbetl or ofleretl for sale(Section 7044,Business Other(See Complete Fee Schedule)_ ► . ..... ..... . . .. . ._ _ . .._. .. . _ ._. . . _.... � and Professions Code�. � � � - - - - CONSTRUCTION LENDING AGENCY - - - � � �� �� -� � - - � - - � � � - �- • �. I hereby affirm that lhere is a construction lendirg agericy for the performance oi the vrork for which this permit Is issued(Sec.3097, pERMR FEE � � � �� � (Sub-Totap S 6 . ._ . _ CW.C.J. . . _._... ._,.� ......___.. - ---... __. .. PLAN CHECKING FEE. _. . . _ _ _ . . . . . . _ . _ Lender's Name � PERMIT ISSUING fEE . �D_ S ' . . ..- . _ -- -- . .. . . _ .__.. _. . .. . _. . . . . .ender's Address /�� �6 �certity that I have read this application and state ihat[he ebove TOTAL FEE � ._. _ . _. . .. tormation is correcL I agree to eompiy with all County ordinanCes � ��d State laws regulztirg Electrical wiring,and hereby avthorize ,� resentalives of lhis County to en[er upon the above-mentioned ' � - � � � �� - � � � � - � � �- - - � �� -" '-- � - � � � �operty for inspectipn purppo�ses. _ , , SEE REVERSE FOR EXPLANpTOPY LANGUAGE __ . . _ . . _ . . f:J.�n..�'''��.�-P 2� -8-8' . . . rgnature ot Permittee D 0 \ .. ��. .-h.�.,� r. — i........ :.. .. .... _ ..__`f ` I- -� i- I�— I^i i� ;--I---i-!'�--- �� �� i�-= � - � i ;- '-. ; � '= � I� ; ,,; i - _ i: � .- � � r . � t. �-- ; -- ! 'E ; - ! 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