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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION 76nss3 ioiat � � I hereby a(firm that I have a certificate of consent to self insure, �E-808G APPLICATION FOR ELECTRICAL PERMIT . or a certificate of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) � Poiicy N�S��(2�8��Company��nLC1'R1AI. �IV�1 FOfl APPUCANT TO FILL IN D�RESS oc��H N�� ❑ Certified copy is hereby fumished. ,. , . New Residen[ial 81dgs.8 Poqf,s_ pp� � EACH. NO. . FEE I - � 1 S 2-Famil F � �S 1 7 `� — 5 LOCALITY V [-uT Certified copy is�(iled with the_county buildirg inspection Y��� �•�� department. ' . � � �' ' � � � Mul[idamily Sq.Ft. — NEnftEST _ .. . " � Residential Swimming Pools . .. OWaER OR � Dato 30 Applicant, FlRM NAME .. CERTIFICATE OF EXEMPTION FROM WORKERS �� � Outlets:Rec_L'ght_Sw.— --- - ' � �"U'�� �� �� COMPENSATION INSURANCE � � � ADDAESS �S . ` V E �(This secHon need not be completed if the work Invoived by tha First 20� Total No. Additional ��T � � 2 Tel.No. Q^ 0 permlt Is tor one hundred dollars[$100)or less.). . . � � � PLAN GHEGK � � - I certify that in lhe perlorm�nce of the work for which this permit �� �� pppUCANT - � -� - is issued,I shall not empioy arry person in.arry manner so as to become subject(o[he Nlorkers'Compensation Lavrs.� . � Ughtirg Flxtures First 20 �- � - -- - �ADDRESS�--- - ���--� . . . � - � . . . � ; Total No. Additional qTY.-. -- - . Tel.No. Date Applicant ' Flxed Appliances Not OVer i HP � PERMI7 � �� {� NOTICE-TO APPLICANT: If, after making ,1his.Certificaie o1 � A�LICAM � FF C �C� �� .Exemption,you shoWd become subject to the Workers'Compensalion _, Range_Heater D.W. _ _ ......:�'....5 0�:M L.9�`O.'CCAe �.nJ M����r,..�M.,ati��mM,.,.,»h�uch ._Oven.._.OryPr VJM._.. .... . .. .. .... D'� �� ,.v,.,..,...... ....,_.._......... .., ..... _ _ . . . ADDRESS � _ .. .. �prrnns�ons or ihis permit shall be deemed revoked. ..�,_ , .. ., Top..— FAU._ W.H._ _ , . _. - CITY���NO � 0 - Tel.Nasq _�y�� . LICENSEO CONTRACTORS DECLARATION� Hood—Fan _Other_ .1 hfi'Eby 0(lifrtl tha�I am licensed under prOvisions of Ch9p�0!9 LICENSE OR p �- DiSp. —ROOm Aif Cond. _ REG.NUMBER" OO p� ' Class.C+IO� ' �(commencirg.with Section 7000)of Division 3 of the Business and . �' Professions Code,and my license is in 1ull forCe and eflecL - ppµ�r Apparatus 8 large Appliances . _ DiSraiCT NO. PaOCESSED BV _ ____ . _ . _. /.� � (1��� Size&Type HP,KW,KVA,or KVAR � V �n� Q License Number y 9Do S3 Lic.Class� - - --�-�"�"-�-� �Up to 7 Incl.- '- - -�" �� � FINAL- -" ' � ' -�-�� - � - � �- �+ DATE � ' /- y- Over 1 to 10 Incl. �7" ?� _ . VALIDATION � /-IECl�LCI��J� �' �ate� .._ . ._ _._... --- _ . � Contractor .. . .-.. - .. . . .. � Over 10 to 50 Incl. Fl�� U ❑ I am exempt under Sec. ,_ Over 50 to_100 Inc. BY , . , , . .. . . W B8P.C.for this reason Over 100 - � N . .... . ._. ... .. ._. Oate.._._.. - -Servims:Swbd.;MCC&Panelboards . - . . -. .-- .. -- -..- . . . . .-... . ._. _.� Z . � 0-200 Amp.Urdei 600 V - � Signature .- .-- 207-1000 Amp.Under 800 V. ..... .. .. . - -..- . . ... ;^1 � $,�.�_ . - �� -� � �- -��- � - -� - - - -- � Over 7000 Amp.or Over 600 V � � ExemDtiontorRe9.Maint.Elect. -- . _.__ ._. . _. _......... .._..... _.. . .. ... . . . . . _. .._ . . �;� • • o.a 2 . -" - �- � �� SiNGLE FAMILY "� ��-�' �" �! Temp.Povrer Pole 8 Appurtenance3 )-• � 2�t!b� - . . _ . _.__. ' ___ _. .. _ .. . .. . .. HOME OWNER•BUILDER DECLARATION Sign with One Branch Cireuit � I hereby�alfirm that I am exempt from ihe Cont2c[or•s License Law Additional Sign Branch Circuits . . .__. - � _ .... . . . • • � 2 G L,p v . for the toilowirg reason(Secfion 7031.5,Business and Prolessions , Codel: ' � _ A�usc.Conduits s conductors _. . . _ . 0�2 6-8 8 I,as owner ot the property,will do the work and the structure• Other See Com lete Fee Schedule is not intended or otfered for sale(Section 7044,Business ( p �— ► . , and Protessions Codel- - . . .- �. ..._ . . ..... . ... .. �.. � . .. .- - CONSTRUCTION LENDING AGENCY � -� - � -�- - I herehy affirm that there is a construction lendirg agency for the � � performance of[he work tor which this permit is issued�Sec.3097,. pERMR FEE� �-� -� � -� -- (�+b-Total) �$' - � -� � -� � � � Civ.C.1. .... ._. . .. .. � PLAN CHECKING FEE --.. . ...._ , _ -. . _ . . .. . . . . Lender's Name � � _ , PERMIT ISSUING FEE � . . . D O � -- -- - � - - Lenders Address /� ( � � I certiy that I have read this applkation and stata that[he above . TOTAL FEE � ' _ 1 a b•y`j - . -. . -- . . . ... _.. ..._. ._ . __. information is correct.I agree to comply with all County ordinances antl State laws regulating Electrical wiring,and hereby authodze • . ._ - ._ ... . . . . . ... . . . . .. . . . representatives of this Caunty fo enter upon ihe above-mentioned � �� �-�� � ����-� � pro rty fo�ur ses. . .. SEE REVERSE FOR EXPLANATORY lAN6UAGE.. . .. . . . . _... -.. .. _. ... . � . . . . Signature of Permrttee � Dat � . .:�c�_'_1..��;'_. �'__... ,-±`""� `�.:� r � �,- i � I �T_ � _i._I-__I_-`=`i . ' (` {- I , I.., I I �, � �, i r- - � I :-- � �" � j, �� ±._. j �` � ; ; ; I 4 ' I - � i- � I ' I � _ I `I � � - 1 i '`- � ; ? : � � � i 1 1 . ` I ` 1 I I �j i ' i I - ( -- I , I �"� I �� � � - f � � - 1 � �"� ! I � ��' � � I_' . i ,- . - --- -�--- - ; i (..� i�'� j F.' ' � i� i .. 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