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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECLARATION 76A663 �a�e� qppLICATION FOR ELECTRICAL PERMIT {� � I hereby aifirm that I have a certificate o1 Consent to 5elf insure, CE-Ea6G or a certiticate of Workers'Compensation�nsurance,or a certified , COUNTY OF LOS ANGELES BUILDING AND SAFETY LJ copy ihcrcoF(Sea 3800.Lab.CJ � . PolicyN����TC�I�363comaam1��DuST2lAL INO FORAPPLICANTTOFlLLIN �� �-: � -- -� ' JOB � ���-� 0��1�I ��ry-�^,� �^/ ❑ Certified copy is�here6y furnished. . , ,, EACH NO. ...FEE ADDaESS T 1 �V+ �JIL , _ .. New Residential Bidgs.8 Po / _ .I�( 1&2-Famil Ft. � = S LOCALITV R. 2 S�6�V L� ,�,� Certitied'copy is fibd��with the county building inspection Y��' rvenaESi.. . �tlepariment. � �� � I C Multi•tamily Sq Ft. � � ^�/p& � ���/J CROSS SL� � - - Date t b o � Applicant //� Residentiat Swimming Pools � � " � pWNER OR I . - , - ' FlRM NAME . � -: CEFTIFICATE OF EXEMP770N FROM WORKERS' - ' � . .� rVtai� \r p . � .COMPENSATION INSURANCE.. ., Outlets:iiec—Light_Sw.— � .�� ,, . nponess3 r s� I Rw i l?l��. � � �(Thia section need r.ot 6e completed H tbe work invotved 6y Ihe Frst 20 ^� .permit Is for one hundred dollars($100)w IesaJ Total No. . AdCitional � - ��T OSl - 62,(Tel.No. O^ O�I . ... .. _ .._ .. I certify Ihat in th¢performa�e of the vrork for which ihis permit - � -� , qpp���M K -� --._--- . _ is Issued,J shall not employ any perspn in arry manner�so as to . . — become sublect to the Workers Compensation Laws. Li�ht(ng Fixtures Frst 20� �ADDRESS -�� �- -- � . . . . . . Additi0nal - .. '.. . '� � � - � � �� � - . Total No. - CITY �--- � - Tel.No. Date APPlicant - Fixed Appiiances Not Over 1 HP 1_ ` p NOTICE �.TO-P.PPLICANT: if, after making this Certificafe ot � APPLIOAM � �[� e\I�C�"tC Exemption,you should become subject to the Workers'Compensation ., Range_Heater_ D W. _ 1• .Pro'.^sior.�c'Cti Le6or Cede,;co mu�•<c�!rvith oc:^cly x^th��h G*.�?n_ C4,e[ A. ADDRFSS� .O. .�Gx `_ .. . — w..�— ' �provistons or this permit shall be deemed revoked. ,�, _ _Top. — FAU _ W.H._ _ .. _._ . -_ � . _. _.. . .__ .CITY-�` � � �D��- TeI.NoS c6 y( LICENSE�CONTRACTORS DECLARATION�� � � Hood— Fan _ Other_ ,1 hereby�affirm ihat I,am licensed under provisions of Chapter 9 p�s LiCENSE OR /�cy p, �(commencing with Section�000)of Division 3 ot the Business and . p�'— Room Air Cord. _ REG.NUMeER /�(�d0 p �3-- Ciass. C��� , Rofessions Code,and my license is in full force and eflecL DlsiFlicr No. eaOCeSSeo sv Power Apparatus 8 Large App�iances . . '(� ¢,�7 Size 8 Type HP,KW,KVA,or KVAR �.� `1\ .� U f�� � LlcenseNumber L�q��U J LiaCiass ���� -_.. � .. LIPto 11ncL - - _ .. .._ . ... ..__.._ . . FINAL . ..- .. ..'.�- .- - . . __ ..__._ . .. (�j . y Over 1 to 10 Incl. DATE/�'�L � . � . � CqntrBCtOt�I�GT2-f C/�L� �� 'pate��.. . ..." - � - - - FlNAL` . . .. .._. VAUDATION_ . O . , ❑ Over 10 to 50 Incl. . I am exempt under Sec. � Ovei 50 to 100 Inc...._ gy,. . o��,00 -- - �1 1-7,3 A - a �.BP.C.for this reason ServiceS,�Swbd.,MCC 8 Paneiboards � -� - � � - - - � �� � � � �2 N .._..._. 9 ...... _.. _ . Date:- Z 0-200 Amp.Under 800 V ^ Si nature � �201--1000 Amp.Under 600 V ��� �� �� - - �-�--� - � -- � � � °$�R 6 . -- �� - � �� - �-- - - �- -��� Over 1000 Amp.or Over 600 V ❑ ExemPtion for Re9.MainL Elect. . . .._ _. . . . .. .. . _ . . . . . _• e e 8 rj,��j�. '���- -` � - � �SINGLE FAMILY- - ---�-- '� � Temp.Power Pole&Appurtenances •��2 6—O II �HOM17E O'NNER-BUIIAER DECLARATION � �� � �-� � � � �-�� �--��-���- - -- - - � � � I hereby alfirm that 1 am exempt from the Contractors Licens?Lzw Sign with One Branch Circuit � for Ihe lollowi�g reason(Seclion 7031.5,Business and Rofessions - AAditional Sic�n 6ranch Ciraiits .__ . .__. __._.__. Codek . ___.__.. __..__ _ ..._ . . .. ._. -_ Misa Conduih&Conductars. ._._ . .... ._ .._. _ . _ .. _. . . . . . ... __ . . ..._ .. .. I,as owner of the property,wili do the work and the siructure p�her See Complete Fee Schedute is not intended or otfered for sale(Section 7044,Business ( �— ► arM Professbns Code6 .. - . ... .. . .�� . . . . . . . .. . .� . _.. . - ... CONSTRUCT70N LEND�NG AGENCY �� - -� - -- �-- ��- - - � � � �� --� ��� �� � - I here6y alfirm ihat there is a cronstruction lendirg agenCy for the � perFormanca ot the vrork for which this permit is issued(Sec.3097, .. pERMR FEE � -� �� - �- � �� - � (Su6-Total) � �� � �- � . . Civ.C.l. ._ _.. .. ... . . . . � . . PLAN CHECKING FEE. .. .. . �_. . .... .. ... . � . � Lendets Name � - __ PERMR ISSUING PEE_: ____ �. _. �O. O . _ . „ . .. . . _._. . . . . . . Lender's Address p. • 1 certify ihat I have read this applica[ion and state ihat the a6ove TOTAL FEE $S•O� ...... _... ._ .__.__.. .. . ... information is correct.I agree to comply with all County ordinances �� � �� � ana State laws regulating Electrical wiring,and hereby authorize � represeMatives of this County to ente�upon the above-menibned � � - - -� - - �� �� ��- - � � -����' -�"'" - - " � prope ty far ins ection pur=� r, �� �� .SEE REVERSE FOP EXPLANATORY LANGUAGE__. . _.. ... _ .... _ ..--. .. ---- - Signature o Permittee ate K�r..��...�� ,, i �—_`-' {�.�r'- -� V�� .,... . ---� J, I- --'` i:- i � -i---;i--I- I'i� � —i'--i :. �� -,i � ��_ � �= ��� -�� �I ;� �, ; �,- ��=; ; �` _ j= I 1 I` .I I ��� � �� � 1 � i � I�_ � I! � . _ ; , � � I i _ f ��': t - • � � �, I , � � _ . �: 'i � , i -- ' I . i . i� t i �` i � _ ; ; , � ! �.' j � � - - - - - � � � ! � I � �- . ;-- �, -- , � , � � ' I:. - M1� � I �- � � i � , �_� � i j ' j I i: t_ I I �i 1 � � � .. 1 j !, I- ; '__�o T � p �� •� `� c '� ; `. i� F' i� -.- m > C .-xi' � � o � 7 „ .�. � �, r � � c! z, .G� m v � ^` .,. . � " I- '__ , � � � c� x � � � :; , � . r � ! i � � cn; " �' � � -o i ;; C... � ' ; j o o � C W �: O � y� i o C � - ( : � ; � � � � , =� Ao � j � �': T � � 1, '� rn m � � m � } ,�, � _ i _ � � � � o o _ . - , � � . -' . , v . 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