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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATION DECLARATION �sass3 �va� qppLICATION FOR ELECTRICAL PERMIT {� � I hereby'alfirm that I have a certificate of consent to self insure, ce•aosc . � or a certif'�cate ot Workers'Compensatbn Insurance,or a certifietl COUNTY OF LOS ANGELES BUILDING AND SAFETY copy[hereot ISec 3800.Lab.C.) � � • POIiCy N0. � 3�Comparry 11]huSTR\AL ��b FOR APPLICANT TO FllL IN . - ' J08 ^�.11 ❑ Certified copy is hereby tumished. . , , - New Residential Bidgs.&P I EACH NO. FEE AooaeSS q� V\1'1� � N � . � .. � . 1 8 2-Fami .Ft.,�'� � � — � LOCALITY �V 2 Ceriified copy is�(iled with the'CouMy buildi - i ection �1'�� � departmeM.�� � ��� �. � �. . - ' ��r � - MWti-family Sp.Ft. CROSSSSL � � - ' " Residential Swimmin Pools �-� -� � Da�e3���'qppliC2fl1 9 OWNER OF n � -� � , - . .. FIRM NAME ' C�y. � � CERTIFlCATE OF EXEMPTION FROM WORKERS' p�tlets:Rec_Light_Sw.— -- � _ '�\ MAIL q � � � COMPENSATION INSURANCE � -� _ �- - - aDDaEss 3 I SI A " �This sectlon need not ba completed R tha work Involved by the Frsi 20 permit Is ter one hundred dolWrs(S100)or lese.) � Total No. Additional CITY S"r . �SA 'N0' 5�.•��0 �I certity that in the performance of the work for which this permit -��--�� "��- '- �'�� • �N CHECK - �is issued.I shali not emptoy�arry person in arry manner so as to ' � ���� — become sublect to ihe Workers'Compmsation Laws. L'ghtirg Fixtures First 20 ADDRE55 ----�- - -� - . .. .�'.. �..�. ., . ... . , � � � TotalNo. Additionai � ...... . .._ Date � ��Applicant • � -�� CITY Tel.No. NOTICE-TO�,APPLICANT:-IF, after making this'Certi(icate of Fxed Appliances Not Over t HP pERMiT�� , � � Exemption,yrou should become subject to the Workers Compensation Ran�e_Heater_ D.W. _ _ ��Car'1T E �`FC � .provisions oi the La6or Code,you must forihwith comply with svch Oven_Dryer_W.M._ ADDRESS'{�Q� p„ .provisions or this permif shali be deemed rewked. �,. . . Top ._FALJ__ W.H.._. . _..._ - ��p.� �N ,r�0� Tel.No.S (�6 . LICENSED CONTRACTORS DECLARATION. . Hood_Fan _ Other_ �I hereby atfirm that.l am licensed under prwisions o1 Chapter 9 Disp. =Room Air Cond.� _ uceNse oft O O �i�s (commencing with SeClion 7000)ol Division 3 of the 8usiness and F1EG.NUMBER� - 1 U O O 3 t.��0� PrOfess�ons CAde,and my liCense is in fuli torCe and etfeCt � DISTRICi NO. PROCESSED BY � _ Power.Apparatus 8 Large ApPfianCes -.- ... . . _ . _ _ ____-.�-�_._ . �O OO�3 , (� `��� Size 8 Type HP,KW,KVA,or KVAR ��, �n 0 License Number 1 Lic.Class �1SL � � - � �� UP�fo 1 Incl. --. .. �._ ... . _ . . .. . FlNAC . . ��p///JJJ - .. _ . � V Over 1 to 101nd. DATE �/ (/�/ - � 'confracfo.E`C-C'�1 C A l.�.. �Oate�� _ ._ . _ . - --- - [.�aa . . . vnuonnoN . .. .p . ❑ Over 10 ta 50 Incl. __I am exempt under Sea � -- � � � �� Over 50 to 100 Inc.__ FINAL V _ .__ ... BY--_ ._ . _ . ... __ . - W 6.8P.C.for this 2ason Over 100 n. . _.. - ... �� Service4.Swtid..MCC 8 Panelboards-.. .. _ _.. ... . . . _- . . - . - _._.�..----. . .. . Z - Date: . 0-200 Amp.Under 600 V ► - �� � 5�8 A " Signature 201-1000 Amp.Under 600 V � � - �' �� � � � -� - - ���-� - � -� -----� � ... .-. . . -. _ ._. - . .. Over 1000 AmP.or Over 600 V #• • • • .2 . ❑ Exemption for Feg.Maint Eied. - � ��� � --� � � � -� -�� - . � I • 11218 - � -� � � SINGLE FAMILY � �-- - Temp.Power Pote 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � ° � � �� C�u . I hereby aifirm that I am exempt from the Contrador's License Law for the(oliowing reason(Section 7031.5,Business and Rolessions Add'Rional Sign Brench Circuits-- -- - �� � � - � � � O H Z 6-S S� � . Code�: Misc.Conduits 8 Conductors � - -" " " - "-�" � �� - � � � I,as owner of the property,will do the wwk and lhe stnKture ' is not interded or offered lor sale(Section 7044,Business ., Olher(See Complete Fee Schedule]_ . . .. . ,.. . . ._. _. ._ . :_ _ .._.. and Professions Code�. � - -� CONSTRUCTION LEND!NG AGENCY -�"- � � - . ..... .... . .._. - I hereby affirm that there is a construction lending agency 1or the performance of the work for which ihis permit is issuetl(Sec.3097, PERMR FEE�-�-- ' �� ' ''- (Sub-Totaq-� �Q bg � � � - � - - --� - - �� � � - -� Civ.C.�. - PLAN CHECKING FEE .�. ..._...__. _.. . . . - . . ....- .. . . . _ . . Lender's Name � - PERMIT ISSUING FEE .... _. .. . . ... . O . . . Lender's Address I certify that I have read this appl"wation and state that tha above -- TOTAL FEE �Ia'/ , .. . _ _. _ inPormation is correcL I agree to crompy with all County ordinances . � � --� � and State laws regulating Eiectrical wirirg,and hereby autFwriza __ __ _ _ representatives of this County to enter upon the above-mentioned - � � � ��� - ���� �----�---- "� � - � - -� -� property for inspection purposes. � `�� ��� �----SEE REVERSE FOR EXPLANATORY LANGUAGE _._ � JSignature ol Permittee p te i � S�� _•,�J�•,• . �_�..._� .. _.:t! _... �,�•_-:"� t-- ~tlt i-- —i` —,^- ^------�-^ I - ..f,.i_I. ___^___`f �� t. F- ,_, ! ! i. � �- ' _ i� I��. ( ' I - , ' � � I - . . . ; j� � � � I . . �, . I`, � _ _ j ,' � ,.' I I,�, I , i J' ': ' . � - I--- � I` I � � j , I ' � � ' - ! I f � - � ; � ; I I � I �= �� � - � i � I - � : � � I � , i `+� f- � ; � � '+ _ ! 'E � . _. 'r. ' � �-- - i � , � .,... � � � � 1� �- - � --- -- --�r ,i i ���_ ! 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