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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECIARATION 78A683 �0,8, qppLICATION FOR ELECTRICAL PERMIT � � I hereby.afFlrm that I have a certificate oi consent to self insure, Ce-soec or a certit�cate of workers•compensatan�nsurance,or a cenit�ed COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3O8.00.Lab.C.) POIiCy Nc�q DI 0 3G 3�pmpa�y]I.�OUSTRII��. 1�J D� FOR APPLICANT TO FlLL IN JOB .❑ .Certified copy is hereby fumished. , , .,... , � New Residentiat Bidgs.ffi P�ools����/ EACH NO. . FEE �DrtESs: (�a � ���� �� �12� 1 8 2-Fami ,Ft.,6_!7_� � — S - LOCALITY Z' -V ° JS ��' Cer{ified copy is�filed wi',h"t county�buiiding inspection h'•�Q � .�department. - �- � �, Multi-family Sq.FL CROSS SL � - �. �Date ,� 30 qpp��a�� Residential Swimming Pools � �- -� � pWr�ER OR ' FIRM NAME - � A L • �CEFfTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_L'ght_Sw.— - ��L y ��� - •� � COMPENSAT�ON INSURANCE - � . �� ADD�7ESS - (This seetion need not be eompletetl%the work involved by the First 20 - permit is for one hundred dolWre(5100)or less.) Total No. Additional�- CIT '��.��Sa (or� Tel.No. SO��p� �I certify"�that in the pertormance of the work tor which this permit . ' . _ , � ^ �nr�cHecK - - �iS issuetl,I Shall nOt 0mp10y any person in airy manner so as to - � �APPUCAM _ become subject.[o ihe Workers'Compensation Laws. . L'ghting Fixtures Fret 20� � � ADDRESS - . ���- - � .. - .. �. . ... � : . . . .'.- Total No. Additional, - -_ _. . . Date � ApplicaM �-� ��- � � CITY-- Tel.No. . �.NOTICE TO APPLICANT: If, after making�.this CertiFieate of Flxed Appl'iances Not Over 1 HP PERMIT � � -Exemption,you shwld 6ecome subject to Ihe Workers'Compensatbn . Range__Heater D.W. _ APPLICAM ( F� � � � C _.._ . provisions o1 the La6or Gode,you must torthwith eomply with�sueh Oven—Dryer_ W.M._ A�DRESS �provisions or this permit shall be deemed rewked . . . _._.Top _FAU-._.W.H.-_ ..._.... . . .._. ��n. - -' - �Tel:No.5 1��=bY6� , LICENSED COPfTRACTORS DECLARATION.. . Hood—Fan _ Other_ I hereby affirm that I am.licensed under.provisbns of Chapter 9 .. D(sp. �—Room Air Cqnd: -_� � � - ��• - uCENSEON )� __.. ..-Clase. / (COmm2nCirlg with 52C�i0f1 7000)0(DiYISi0f1 3 Of IhZ BuSif1ES4 Zr7d - � REG.NUMBER--] �� � `(� Plpfe55ipnS CACO,8nd my IiC@f150 IS itl lull}OfCB and 01(2CL . �ISTFICT ND. PROGESSED BY _ Power Apparatus 8 Large Appl'iances . . . .. _ _ . . . . .. 1 . . . _. . . . M . _ . . , (���,� Size 8 Type HP,KW,KVA,or KVAR Q . 11\q�`O•(�e 0 License Number y q ooR�a �.Class��L_ ....-... . . -UP to i Incl..-.. ... . . .. . . .. .. FlNAL-�� �^ - -- -- -- �- --. .. . V �I�T . . Over 1 to 10 Incl. � DATE ..CoMiaclor R(CAL �� Date� � y/�� . ..... � . - VALIDATION 0 ❑ Over 10 to 50 Incl. FlNAL ~ I am exempt under Sec. • - Over 50 to 100 Inc.._.. gy.. . _. W .. B.SP.C.lor Ihis reason O�er ioo �.._ ... .-- -� - �1 1 6 9{'i � . ... .. . . - �Services��Swbd,MCC 8 Pa�lboards._ . .. . ..._ -. �. . . _. . ...--_. . . .. . Z -�Date: 0-200 Amp.Under 600 V #• . . .2 � • Signature �-� ���-201�-1000 Amp.Under 600 V � - � '� � -��� � ���� �-�" -- --��---- �� � - - � �- - �❑ � � � � � �- - Over 1000 Amp.or Over 600 V � • •q 6,2 6 Exemptbn for Reg.Maint.Elect. - -- �- - � - � -�-� �-��. - --- -- a � oq62ci� � ��SINGLE FAMILY� -- � ��� � Temp.Power Pole 8 Appurtenances .. . HOME OWNER-BUILDER DECLARATION Sign wRh One Branch Circuit � - �- � �� � �� �a 2 6-a 8 I hereby affirm that 1 am exempt Irom the Contractor's License Law for ihe foliowing reason(Section 7031.5,Business and Prolessions �Additionai Sgn Branch Cirwits _. . . _ _ .. .._ .._.____. . . Cadel: .. . ._� '� -Misc.Conduits 8"Conduc[ors..- .. . _ . . . .. .... ... . . ..-.-.... . . . ..._ . - --.. 1,as owner ot the property,will do the wwk and the structure is not intended or offered for sale(Section 7044,Business , Other(See Complete Fee Schedule)_ � _. _ .. .. --- . ___ .. ..__ znd Protessions Code�. �- �� � � - � � CONSTRUCTION LENOING AGENCY � - � - - - - � - - - ��-� - � I he2by affirm Ihat there is a constniction lending agency tor the �� ' performance of ihe work for which ihis permit is issued(Sec.3097, - pERMR FEE- � "- -�'--� �---- ��-�- � (Su6•Totap�� ' --- ��- - - -�-�-�� � -��- - - - � � � Civ.CJ. - PLAN CHECKING FEE. . -.. . _.. ._ . _ ._.... --- .. . . _ . . . . � . � .., . _ ... _ . . . _. ._ _ . Lenders Name . . PERMITISSLIWGFEE.. .. ..__ . .. '__ . ._ ... _ I� SO _. . . . .__ . . _.._.. _ _._. . . _. _ . . Lender's Address � � 1 certify that 1 have read this application and state that the above TOTAL FEE.._ .. � q'���6 iMamalion is wrmcL I a9ree to comply with all Cwnty ordinances . � and State laws regulatirg Electrical wiring,arid hereby authorize _ _. � ._._..._.. . ........ .._ .... . .. . . represeniatives of this County to enter upon the above-mentioned ��- - - � _ � - �� �- � - - � ' prpperty for inspection purposes. SEE REVER5E FOR EXPLANATORY LANGUAGE ��. ��� a- - __ _ _ _ _ _ Signalure ot Permiltee 0 te - - T�� � r.�-.f`.1., -:�, � ____.,.... . i_..._.... _. i,�...,� �---- �-- --� -_I_ _ -_�_____ _ ___1_.-;_ ±��.� �. i ' � ! ' � I �-� � ! ; �= i� + � i � `M_ i'- � j I; 'I; _ � --- - i- i, ;I - � i ; I � i�' ; � I �' � ' ; � -. :� I_ ; - ; ; ; ; ` '� i �,�..� ��_, i: � � . 1_ � i - i i i :__ �' _ ;' , �_ ,, , � � I � 1 ���� ��_ �� , �" o i �'r — --- � ! ' - , i �. �- I'_ I l � i_ � i.� ... i �� i, ^ -c , ' � : , ' �_ ." '• _ 1'z ?i c v T �I a' c '�--i � :: �, . 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