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HomeMy WebLinkAboutNo Permit Number WORKERS'CONPENSAT70NDECLARATION� 7sn6e3 +o�e+ APPLICATION FOR ELECTRICAL PERMIT � � I hereby affirm that I have a certificate of consent to self Insure, CE-eosa � or a certiticate ot workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy[hereol(Sec.3800.Lab.C.) Policy No.C' 01 363 �mpa�y 1 I�)V�+STKIf�l. IIvQ FOR APPLICANT TD FllL M .. .. .... 'mg g U�� (��-RR � - .. EACH NO. FEE �DRE55 Certified copy is hereby furnished . New Residential Bldgs.&�oo�is�/!/ � � . . . 1 8 2-Famil S Ft.QSI�[_ 5� = g LOCALRY �6'v rd �� �Certified copy is filed with the county buildirg inspecti Y� 4� � ��department. � �• " -� Multf-(amily Sq.Ft. CROSS ST. � � � � � � � Date 3o cg&' Apptican[ �r Residential Swimming Pools , FRM NAME llRf� Ery � � CERTIFICCO PENSATION NSUR�CEORKERS' �- _ --, - � . �� . qppqESS �I S��- (2(,v U�. ,IU�� - Outlets:Rec—L'ght_Sw.�— �(This section need nol be compteted it the work Involved by the Frs�z�� permft is for one hundred dollars($100)w less.) � , . Total No. Add�tional-� -- CIT . �6�6 Tel.No. Q-�UO I certity that in the pertormarxe�ot the vrork for which this perm(t . ' � �: � ` �p����K� � ._ _ ._ . __....__ .. _ _. _ Is issued,I shall rwt empby arry person In arry manner so as to � � _ become subject to the Workers'Canpensation L.ws... . L'ghting Fixtures Fret 20��--� - - - - AO�RE55 -��-- � � � � � �. �Additional Dale � '- Applicant � � � - . � Total No. CITY � :- � � Tel.No. Fxed Appliances Not Over 1 HP pERr.ti1 '� '� /1 �� J�%�Tn�C NOT�CE TO�APPLICANT;.If,�alter maki �this Certi(icato ot � C � .ExemPtion. 1 � P _ Ran o_Heater D.W..__ . . .. . APRiCnnfi t7' . C. . /�` ... you should become sub'ect to the Workers'Com ensation 9 provisions o1 the Lahor Code,you�must for[hwith comply wiih such Oven—Dtyer_W.M._ ADDRE55 �� �y provisions or this permit shail be deemed revoked.. -. . . _.._Top. _FAU ._..W.H____ _____ .. _. .._ . . q t� (� . . � . LICENSEO CONTFiACTORS DECLARATION. . Hood_Fan _Other_ ��� (111(9 l�"/0 9 Tel.No��6 y( �I herebY effirm that I.am licensed urder provisions of Chapter�J� �-DiSp.�—Room AIr Cond. �_- �-� -.- _ . uCeNSE OH p . . . �C�ass- (COmmenCing With SeCiion 7000)of�ivf5ion 3 of the BU5ine55 ard REG.NUMBER d�p� � R'o(e55ion5 Code,and my IiCenSe i5 in full forCe and e}(eCt. � .ppy,ref�AppafatUS 8 Large Appliance5 . . .. D�STRICT NO. PROCESSED BY - . . _ . .__. .. . . . ... . q n p Q�2 Size 8 Type HP,KW,KVA,or KVAR � O 1�•�� p i�P �4 LicenSe Numher Ll/��U v Lic.qass ��,G �- ��- - UP to�1 IncL.. . .. � .... . . ..- . . . . -. FlNAL -- - -`/.�_. . _ .. -. " co���a�io�E�C:e7�/'�cCAL ' oaie t/ _ wer�roioioa. oa.re �—Z��S! _ � . .._ ..... ..VALIDATION. Over 10 to 50 Incl. FlNAL V .❑ �am exempt under Sea . '... .. . - . . . Over 50 ta.100 Inc.. . BY--..- -�- --' � -- - --.... - ..-...- . W Owr 100 � n- B.&P.C.lor th�s reason � � N . __ . . .. . _. . . . .-Ser"vices�Swb�d..MCC�8 Panelboards_ .--'-._.,. __ . ._.. ►...__._. . _ . . . . . .. ._ ... _._ _. Z . �� 'DStei-- 0-200 Amp.Urder 600 V Si nature � � - 201�-1000�Amp.Under 600 V "� � �� �-� "�' -�"- "�-� �-- -�-"---""- � � 9 rn,z.,000 n�,a.o�o�.soo v �1 1 6 6 A . Exemption for Reg.Maint Elect. - � � -�- --- -- - � - p. . eam2 -�� � SINGLE FAM�LY ��-- - � � � .Temp.Power Pole& .. . Appurtenances . _ . -_. __.. ' HOME 01VNER-BUILDER DECLARATION Sign with One eranch Circuit I ' •4 6 2 6 � I hereby affirm that I am exempt(rom the Contractors Lice�se Law .Additbnal Sign Brench Cirwits ���� for!he fo!lo�ving reason(Sectlon 7031.5,Business znd Pro.=ssions "- � �:� �� � • • :9�U�(�� Code): ❑ I,as mvner of the ro r� w➢I do the work and the structure Misa Conduits"8�Conduciors � - --" - � - �- --' - - � -��- � _ �-" � � " �"-�� ��Q 6-�i 8 P ce Y' • Other(See Complete Fee 5chedule)_ � is not inteMed or otfered for sale(Section 7044,Business . . . . , ._. _ . . . . . _. _ _ .... __. and Professions Code). � CONSTRLICTION LENDING AGENCY �- � -- �- ---�� -�- �-�- - - � ��`� - I hereby affirm that there is a construction lending agency for the � performance of the work tor which this pertnd is issued(Sec.3097, - �pERMfT FEE� � - � � -� � �� (Sub-Totaq '-g',S � � � --� � - ��' � ' '- � Civ.CJ. .. � � . . - PLAN CHECKING FEE �-� - � -- - - --- � � � �- � - -��- -�� - - Lender's Name � � . PERMR ISSUWG FEE _ __... . __. .... . ...IO- O -._ ........_.__.._.__ .. .. . ._. __..__ _. _ .- . Lenders Address . q/� �nf � � I certify that 1 have read this application and state that tha above TOTAL FEE. . . ... . . .... ...... .. 1 b db . . . . . . _. . _.. .... _ .. _- - informafron is correct.I agree to comply with all County ordinances and State law5 regulating E�ectrical wirirg,and hereby authorize , . . . . , , � . _ . . _. .. _... . _ . . �.__ .. _.... . ' representatives of this County to enter upon the above-mentioned , . - � proper y(or insp lion pwpos . . - SEE REVERSE FOR EXPLANATORY LANGUAGE - � - �- - . . .. . . . ._. .._ _ . �- r 8' 22 �" Signature of rmidee D�te � - .. ..,. �.�_f�..:� L.i'_.�� �_' "'� i•, _ ; - —i- -/ � i- � _-�_._�^__ � ,-�_j_'_ �,�~i-�{ _ � � '� � I � �' � � i I li J�: i✓. ' I y ,� I I ! I� � �4 t i` t< � I " i � ! r �, � . � - I � ._= i i r _� ; i...', i • 1 � ` I � � I. . I ( �- � f � �" % _ � j I i � I - � _ '�- :I,' � ]. 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