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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSA710N DECLARATION 78Ae6s t0/et ' � � I herebq affirm lhat I hm+e a certificale o�consent to 5e��inSUfe, CE-806G APPLICATION FOR ELECTRICAL PERMIT or a certificate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) �1 n^^ Pollcy ND. �� V 3 COmPaM���US��IT� (1v�J � FOR APPLICAN7 70 FIIL M � DDRESS� Y� �� V�� �AM1���2RT J'� ❑ Certified ropy is hereby fumished . . . . New Residential Bldgs.8 P°�Is�Lf � �EACH. NO. � .FEE �—�-R y2 S '�6�V �I� � 1 8 2-Family,Sq.Ft..�L1� LOCAU , Cedified Copy IS filed With the CWnty buildirg inSp tl0n NEAREST . dep ment -� � �: Multi•family Sq.FL Cttoss st � � Date �O� � App�icant � Residential Swimming Pools � -- � � � -- pWNER OR FIRM NAME . .CERTIFlCATE OF E%EMPTION FROM WORKERS' . putlets:Rec—Light_Sw.— '"� MA�� 4 - . . .. COMPENSATION INSURANCE .� . . � - `• a�oaesS 3 J S� E. (This section need not be completed II the work involved by the Frst 20 - , CIT Tel.No.��y �permit is for one huntlred dollars($100)or IessJ Total No. AdCitional � O$ 4 26� OJ�� DO I Ce�tily that in Ihe pef(Ofmdnc0 of ihB work tOf Which 1hi5 permit' � ' . . PLAN CHECK. � APPLICANT — is issued,I shall not employ arry person-in arry.manner so as to � � :� � - - — become subject to the Workers'Compensation Laws. . Lightirg Fixtures Frst 20:... �ADORESS- -- -- ' � Additbnal . .. . :�� . .: ' .. . ' -.. . ':� Total No. ... CRY- . . . . Tel.No.. Date - -Applicant � F(zed Appiiances Not Over 1 HP PEHMIT \ NOTICE TO P.PPLICANT: I(, after making�this Certilicata of . App��pM� C � `;l�C���C Exemption,you should become subjec�b Ihe Wakers Compensation., Range_Heater �.W. _ ... _ . .- -� -- '--_. ._ _ _ . . . ADDRE55 , provisions of ttu labor Codz,yau must'artkr:ith ccmp'y v:;h ar'h O:bn_L4yer_W.M._ �Q� �� {�� �provisions�or_this permit shail be deemed rewked, . ,._, __Top —FAU __W.H._ . _. _. �- GTY C�-��p� I��O - Tel No�/-(�[ �o � LICENSED CONTRACTORS DECLARATION Hood_Fan _Other— � .I hereby affirm that I am licensed under provisions of Chapter 9 _.DiSp. —Room Ai�Cond. — ��CENSE OR ���g (commencing with Section 7000)of Division 3 af ihe Business and REG.NUMBER �G 3 ���0 . PfoFesslons CAde,a�rtry�eOns�s In fuli�rC and eftfCt. pp�yer Apparatus 8 Large AppliarlCe9__.„ DISmIG�NO. PROCE55ED BV ��____ ^Ct�ct`o�n e � /1��,� Size 8 Type HP,KW,KUA,or KVAR p License Num6er � 3 lass�1.(,L'��- �- �� � Up to 1 Ind.-- - -� � �� � � � FINAL q �Q/� �- � ����- '� - 0 EyEcT�Zi c�-L ` y 8- Over t to 101nc1. DATE�/�/Y� VJ{ . VAUDAl10N � Contratror Date - ---- - �� d�/ � O- � � Over 10 to 501nc1. FINAL ' � ❑ I am exempt under Sec. - - - � _ . ____ .Over 50 to 100 Inc. BY_... � . _ . V W B.&P.C.for this�reason Over 100 _ . � - �� Services.Swbd,MCC d Panetboards .. _. . . . _ ,. . .._..--- . -. . . _.. . - .. Z - Date: 0-200 Amp.Under 600 V � � Signature � ��� �-201-1000 Amp.Under 600 V-� � � �- - -- - - � - � -- - ' �- -� � � �.�� � � � - ��-� - --- � � � Ooer 1000 Amp.or Over 600 V � . �� Exemption for Reg.Maint.Elect. . . . - -.. -. . . - _ � . . . . <� � �5 A _ .. _.. ..__. ... _...... _.. .. �� - -� --- �SINGLE FAMILY � �- ��� � - Temp.Power Po19 8 Appurtenances� �� � � �2 � � � � HOh7E OVJNER-BUILDER DECLARATION � � ' ��� � � -� � -� --���� -� � � � � - Sign with One 0rerxh Circuit - � . .9 b.2 6 1 hereby affirm that 1 am exempt Irom the Contractors License Law pddltional Sign Branch Circuits - . _ . .- for the folloxring reason(Section 7031.5,Business and Professions �� � � - � � �- Code): . , e o e C)(x 2(��_., . � Misc:Conduits 8 Conductors � �---. . . .. - .-.-..� �- .. .� . . ❑ I,as owner of the pmperty,will do the work aM the structure 0 8.2 6-$8 is not intended or offered for sale(Section 7044,Business �ther(See Complete Fee Scheduls)_ ► and Professions Code). CONSTRUCTION LENDMG AGENCY � - - - � � - ��- ��� -' - - - � � I here6y aF(irm ihat there is a construc�ion lending agency tor[he � performance of ihe work for which this permit is issued(Sec.3097,_.. .pERMR FEE- � � �� - �� (Sub-Total) -g'S �� -��- � -� �-� -- -- � - - � Civ.C.). ._. .PLAN CHECK�NG FEE . - .. . . . .. . . ... . . .. . . . . Lender's Name . . PERMR ISSUING FEE . . ._. . (� SO . ' . .. . _ .. ..... - - .Lender's Address �1 � I certify lhat I have read this app�ication aM state that the above TOTAL FEE � Fj„(� , _ . , , . _ � . ._ .__ . ._ ... ... .. . . . .. . information is correct.I agme to compiy with all County orclinances � � and State laws regvlating Electrical wiiing,and hereby authorize representatives o1 ihis County to enter upon Ihe above•mentioned� �-- -� ` � �- �� � - �� - - � � � prope y for inspection purpo s. „ _ . SEE REVERSE FOR EXPLANATORY LANGUAGE �`' � S, b,,�' . _ _ _. Signature of Permittee Dat � � � ' " � p., ,.. .i�� :i i. ..-.. . 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