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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSAIIONDECLARATION �6As63 �a�8� qppLICATION FOR ELECTRICAL PERMIT � � I hereby alfirm that 1 have a certificate of consent to self Insure, CE-sosG or a certi8cate of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY. , Copy therepf(Sec.3600.Lab.Q) r Porcy N�J9AlR3C.�r=mpam,��1�s1 R`�� ���n FOR APPUCANT TD flLL IN J06 � ❑ .Certified copy is hereby}umished.. � EACH NO. ._ FEE . AooaESS� -s . . ,� ; . . . New Residential Bldgs.&Po��C�^�/ LOCALIT �1 S�/� J `� Certified copy is filetl with the�county�building inspec6on 1 8 2-Family,Sp.Ft.1_SL[— g — g .tJr/b V � : l� depaftment: . . ' Mulli-f3mily Sq.Ft. — NEAREST � , . Residentlal Swimmin Pools CFO55 ST. � Date 30 rS: APDlicant C 9 . . OWNER OR 1 �--� . FIRM NAME `C � ����CERTIFICATE OF EXEMPTION FROM WORKERS' � p����s:Rec—Light_Sw,— � "" . '�� - �� M^�� ` � � C 4 .��. �,- COMPENSATIONINSURANCE � - � - �� � ��� - � qoDRESS-31-SI ._ , .(This seetion need not be eompleied il the wak invoived by the � . Frst 20 � � � permit is for one hundred do1Wre($100)w IessJ , � Total No. Additionat - CITY S�` � � �• $s�-�00� I certify that in the performance ot the vrork for whkh this permit � . _ ._�. _ r�-nN cHECK� , �is i55ued,I Shall rrot emp�oy�any person in any manner so as to � � MPUCAM. � � _ become subjed to the Workers'Compensation taws. � Lghtirg Fixtures Frst 20- ` � -�� �-- --- -�- � ADDRESS �- � � . . . �. . � :, -� Total No. AddiFronal___ ._..._ . . . Date �� Applicant - CITY _ Tel.No. Flxed Appliances Not Over 1 HP pEpMii � .NOTiCE TO APPLICANT: If,�a(ter makirg this Certificate ot APpLi�ANT • ( ��L � �L�R�L � �Exemption,you should 6ecome subjxt to the Workers'Compensatan _-. Range_Heater_ O.W. _ _ __ .. . _. �provisions ot the Labor Code.�you must forthwith comply with wch Oven_�ryer_W M._ � . ADORESS � b � pmvisions or[his permit shall be deemed revoked., � __Top. _FAU-_ W.H.__ . qTy '� -TeL No. �(��61 _ C �iv6 t'�b 5 - •- LICENS[D CONTRACTORS DECLARA710N. .. Hootl_Fan _ Other_ �I hereby,aftirm thffi�I�am licensed under provisions of Chapter 9 --Disp.�_Room Air Cord. ��_ ucENse oR L,p [commencing with Section 7000)of Division 3 of the Business and � aeG.NUMeea��( ( 0 O g 3 --- �� - Ciass.C��Q PrOfesslons COde,�nd my license is in full force afld efteCt. DISTR�CT NO. pROCESSED 6Y _ Power Apparatus S Large Appliances -.- . .... p, p�7 (���n Size 8 Type HP,KW,KVA,or KVAR � �� �1, Q p� � License Number y !��O-�] Lic.Ciass=L_ .'.. ._.. . . .. UP to 1 Incl. � - �- .... .. -.�. .-��--. .. . FlNAL .. . . .. .. . . V . e Over 7 ta 10 Incl. DATE � � Date VALIOATION._. _ cor���aoror ��EC�/�I C/�I-' 4.;�9 pver 10 to 50 IncL FlNAL��r2 � .❑_I am exempt uMer Sec. �� ��� � - � � . . ..... Over 50 to 100 Inc. gy... ' V � �. -. _ ..._. . .. . .. .. . . BRPC.for Ihis reason Over 100 ���� C. � . . .._.._ . ..__ - -Date: ....... .� . .Service5�Swbd..MCC 8 Panelboards.. .. ...... . _--_. ... _. �. . �.. . .. _. . .- . _ .- _ .- Z . 0-200 Amp.Under 600 V � � . Signature -- '-�"201-1000Amp:Under600V��� " - -"� --� - - ---'- - � -� �'��� 7�Q�-���� ❑ � � -� Over 1000 Amp.or Over 600 V � - ExemDtion for Reg.Maint.Eleet �� � � - - ._.�• • • •...2 - � � -�� �-� �'��- SfaGLE FAMILV��� � ��- Temp.Power Po�e 8 A - PPurtenances . . . .. _ .. . . _ _�.• .8 5 8 6 HOME OINNER-BUILpER DECLARATION --- -�� - - ��� I hereby alfirm Iha�I am exempt(rom the Contractor's License Law �Sign with One Branch Circuit for the followirg reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits - - __. _ ._......._.: . .... _. : . __ • e •fi 5 u 6 c=.o , codel: 08.26-88 ❑ I,as owner o(ihe property,will do the vrork and the structure MiSc:Conduits&ConduCtors -` `" " � �� �� � - -�� - is rrot intended or olfered for saie(Sedion 7044,Business Other(See Complete Fee ScheduleJ_ , and Professions Code). � �� � � � � CONSTRUCTION LENDING AGENCY � � �� � -- -- -- � � � � � � - - -.- I hereby affirm that there is a constr�ction lendirg agency tor the performance of the xrork for which this permit is issued(Sec.3097, -pEqMR FEE �� � �--�----� - (Sub-Totaq- � s � �� - �- � �- - - - - - Civ.C.l. � . - � �PLAN CHECKMG FEE. . .. -. - . . _.-_ .- . . . ._ . _. . . .. . _.._ . . LendePs Name - � - PERMILJSSUING FEE . .._ . . .. _ ..- l� S� . _ __. _ Lender's Address I certify that I have read this applicalion and state ihat ihe above . TOTAL FEE _ . $S� (g information is cormct.1 a9Re to compiy with all County ordinances -��� � � and Stale laws 'egulatirg Electrical winng,and hereby auihonze . _ , � � . . _____ . . _ . .. . representatives of this County to enter upon the above-mentioned --- - ��- �� ' �� � ��- � - � "� " " proper�y 1or inspection Wrpos s. � � '-�!J,��7 --� SEE REVERSE FOR EXPLANATORY LANGUAGE - . � . . _ _ Signat�rmittee r � 0 te _._ _. . . . . . _. . _ __. .. _. _ . 1�..... �.���..ri., r.�_ . 4�~,� i i -_� -'r -`- - �. .�._ i`,_.'_...f I_ ._I i..,_, _ _ � i- j- ! , — -� :-.r_ I ; _ � _ ;. . , ;_ � . I- �', ; i `=, ; ; , ;, _, � I-- ,. - �-- 4 ��' � �• � -'i, ; r- �' '.. i� , j - , _ �, . � . �: ;.: '�_ � ; - i � - , �= i. . I; ; -� _. _ ;� I ' , � ' � , '�. . . � , . ��i - � i ._ I . i i � � -'. 1 - 1 � _ � ; � .. . ' I` � � _ - _� . 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