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HomeMy WebLinkAboutNo Permit Number (4) WOFiKERS'COMPENSATiON DECLARATION 76n683 70/81 � �1 � CE-BaeG APPLICATION FOR ELECTRICAL PERMIT � � . I here6y affirm that I have a certificate o1 consent to self insure, u or a certif�cate of Workers'Compensation Insurance,or a certified COUNTY'OF LOS ANGELES BUILDING AND SAFETY copy thereof-T(Sec.3800.La6.C.) ' Po�icy NO.�SS_`�1 A�6.pOmpenq�UDU STR1�.L 1�'D FON APPLICANT TO FILL IN . ... - �B . . ❑ Ce�tiFied co is hereb fumished. ., ,. „ . ,, . EACN NO. ._ FEE . ��ESS � �J�E�� vr r N�ae5�ee�u�i eia95.a P ,�yy s o — s s �'�Y2 S�G-v �07'2 �' �ICf 7 8 2•Family,Sq.Ft. — LOCALITY �d -�Certified�copy is filed with the'county 6uildirg inspection NE.wEST- . departmeM.- - � � Multi-family Sq.FL � Q - ' f . ___ . GROSS ST. Date � � � Applicant � ReSidential Swimmirg Pools pWNEa OH - . FIRM NAME� �-' �� CERTIFICATE OF EXEMPTION FROM WORKERS' . Outlyts:Rec—L'ght_Sw.�— � - � ��� � �� � � .�� � � � COMPENSATION INSURANCE , � ,- � - � - ���-'.�-� . AD�RESS .I.._ C � :(Thia sectkn need not be eompleted if the work involved by the First 20� �1 n permlt is for one hundred doltars�$700)or less.�, � 7otal No. Atlditional��- ��TY\USTt> CS .�'�6`.0 e�•No. � � ' PLAN CHEGK � I certify thal in the pertoimance of tha work for which ihis permit . � -�- � � - - �� ppRiCnN7 - -- - - ,is issued,I shall not employ ary person in am manner so as to � ' ' - become suGject to the Workers'Compensation Laws. . , Lighting Fixtures First 20: �� ' �- A�DRESS �� �-��� - - ��� �� � - � Additianal � - � �� � � ' � � � - Total No. � CITY � � � - --- Tel.No. �ate �Applicant - Flzed Appliances Not Over 1 HP pERMIT � -NOTICE�TO APPUCANT: If,.after making.this Certilicate of � qPftlCnM � �C�. 1'C LC �.Exempfion,you should become subject to the Workers Compensatpn __ _,,_�ange_Healer_ �.W. _ provisions of the Labor Cotle,you must forthwith comply,with such Oven_ Dryer_ W.M._ � ADDRESS n iq 6 , .provisions or�this permi[snall be deemed rewked.,�� � ,._ _ __7op.__ FAU _ W.H._ . CIT`� �t �g�-� Tei.Na _6�rbr � UCENSED CONTRACTORS DECLARATION. Hood— Fan _ Other_ I hereby aHirm that I am licensed under,provisions oF Chapter 9 uceNSE oa p.�7 (commencing with Section 7000)of Oivision 3 of the Busiriess and Disp. ��Room Air Cond.�_ �OO O S- - ��58�C��O � � -' REG.NUMBER� Professions Code;and my license is In full force arM effect. p�r Apparatus 8 Lar9e Appliancee DISTFiICT NO. PROCESSE�BY p p, Size&Type HP,KW,KVA,or KUAR � � � �./ � � 1'lCl`V n� �Q License Number� I �d 0 3 Lic.Class �_�U � ' - -� �� � Up to 1 Inel. �`-- � - -�- - - - "- "- " '- FINAL - rV�1 � � �� -� � ��� ��`�� v �(.�CTRICR-L" 'oate' '��� ��to 10lncl. �A� J� rQ � VALIOATION 0 Contractor - ' - � Over 10 to 50 Incl. � � ❑ I am ezemp[under Sec. FINAL V __ Over_50 to 100 Inc._ ., BY,_ � . . . ._, „ W. � 88P.C-tor this reason � Over 100 � N � Services.Swbd.;MCC-&Panelboards. . ..___. .._. _._. ._- /- ._- -__ __... ._ .--. Z -- � �� � - �Date: -�- 0-200 Amp.Urder 600 V - � s9�am�e -- -- 2oi-i000 nma.unde�eoo v <1 1 6 8 A ..� . . � . . ... -. Over 1000 Amp.or Over 600 V .� �. . . . ._ .. ... ... ... __.. j� 2 . • • s o . Exemption for Reg.Maint.Elect. � - ----- �---- - � � - - -�- - --� ''� � -'�-� SINGLE FAMILY �-�-- ---�� Temp.Power Pole 8 Appurtenances � � ° •9�2 b HOME 01"JNER-BUILDER DECLARATION - �� -� � � ��� �-� - - � �� Sign with One Brarich Circuit x I hereby atfirm that I am exempt trom the Contractor's Lkensa Law pdtlitionat Sign Branch Circuits .._ • ° !9�2 h y for the fol!owing reason(Section 7031.5,Busir�ess antl Professions �� - � - �- ��- ��� -- -�� � -� - - -� code): 0 II 2 6—8 8 ❑ ��� -Misc:Conduits&Conducrors--- � � - - - � --- -- � - � - � � I,as owner ot the property,will do the work arM the strueture Other�See Complete Fee Schedule)_ is not inlended or offered fa sate fSection 7044,Business . and Pmfessions Codel. . . .. . . . . -.. __. ._. . . ... _ . . ..... . _ CONSTRUCTION LENDING AGENCY �-� � -� -- -�� -�--� -- -- ��- - -- - � � 1 here6y aFfirm that there is a construction lending a9enty for the , performance ot the work for which this permit is issued(Sec.3097, -pERMfT FEE� � � � - - � �(Slib-Total� g-S �6 �- - --- �- - � - - �� � Civ.C.l. � � .PLAN CHECKING FEE _.. .._... ___ . .._ .. . .... . . . . _ - - Lerxler's Name , , PERMR ISSUING FEE. , ____ . .�O SO �---._ . _ _ . . . ... ._ .. .. Lerder's Address TOTAL FEE - , �b•o(1p � I certify that I ha�.e read this appl'�cation and state that the abwe . .. . .. . ... .. . .. .. . . . information is correct I agree to comply with all County ordinances � - and State laws regulating Electrical wiring,and he�eby autMrize � representatives of this County to enter upon the a6ove-mentbned -� - ������ � � � �-�-'�� � � �- � � � � �� � � �- -� -��� � � -���� � � � proper y for inspection purposes. .,.... SEE REVERSE FOR EXPLANATORY LANGUAGE , n �fL�¢� ._--_._. .. .. ._ .. . . . .. ._ ... . Signatura of Permittee � 6 �D te . �,.. r . t. _,.. i. 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