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HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECLARATION 76A663 �oie� qppLICATION FOR ELECTRICAL PERMIT � � I here6y 2flirm Ihat I have a-certificate oi consent to self insure, CE-B06G . � or a certificate ot Workers'Comoensacwn�nswance,or a cenitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy�thereof(Sec.3800.Lab.C.1 PolicyN��ROI�3�Compg�ylU�Ug�Q.\(}l I�J� FORAPPLICANTTOflLLM� ., - �B '9 �N�(���A� � . . EACH . NO. ..-FEE. A�DRESS u p��t� Certified copy is here6y fumished. New Residentiat Bldgs.8 Po�ol�p � �O _ S . LOCALITY�j�.�2,S/�-�/ Lo�% �- Certifietl copy is-fiied with�the�county buildirg in e ion 7&2-Famiry,Sq.Ft ' �y - departm2nt.� � . � � Multi•family Sp.FL — rvEARESL_, . . - c1 LROSS SL � �� Date� 3a 4 Appiican _ Residential Swimmin9 P��` � , OwNER OR Q np p FIRMNAME �]I\limR �17 , CERTIFICATE OF EXEMPTION FROM WORKERS' , p�tletx Rec_Ltght_Sw.— ""'"" , �� i:•.• ; MAt� �2 (� 4 � -� COMPENSATION INSURANCE , � , -�� -- - �-� • AD�ReSS V�Sl� SL�.J A 11V C (Thle section naed not be completed if the work Irwolved by ihe Fret 20 permit is for one hundred doliars($100)or less.). Total No. Additbnal ��T�� mE� 4, G'�(Qel.No. -�00 � � � PLAN CHECK- � . I certify,that in the perlormance oi,the work for which this,permit ; - � �. APPUCMrT --�- � - is issued,I Shall not employ.arry.person in arry manner so as to - _ become subject to the Workers'Compensation Laws. ,� � L'ghtirg Fixtures First 20 - ADORESS � - - -- �� �� , � . � � � �- . Total No. Additional -���;.. .. . Tel.No. Date � � ApPlicant - Flxed Appliances Not Over t HP - P�Ii7�M �, ��, t�, CZ NOTICE TO APPLICANT:�Jf,.after making�this.CertifiCate of C C E (�L Exemption,you should become subject to tFre Workers Compensal'an ___, ,___ �lange_Heater_ �.W. _ � . . _ . ._. ..._. ._. . .pro:isions c';h�Lc�or Ccde�Y=�•n__r�_•��••,;�h r.,•,��y�•^rh�u�h Ovon_DrYPr_ W M._ ADDRE55 . ^ OY � . :pmvisions�or ihis permit shail be deemed revoked.�� . ,_ . Top___ FAU, _W.H._. _. - .__.____. ---- CITY� � 0- 1�p �Tel.No.SqI�6 yb� � LICENSED CONTRACTORS�ECLARATION. .. Hood— Fan _Other_ 1 hereby affirm that I am licensed urder provisions of Chapter 9 _ L�CENSEOR Ll,p -7 _ .__��g' �/O (commencing with Section 7000)oF Division 3 of the Business and - � �isp. —Room Air Cond.-- pe�.rvunaBER-� 1 1 �� J -C � pro1es51ons Code,arM my license is in futl foroe arW eflect. Power Apparatus 8 Large ApplianCes DiSrniCE No. PROCESSEo Dv • /�_/� Size 8 Type HP,KW,KVA,or KVAR U 1 '���`��'��' O License Number a O � Lic.Class� . _ ... . . .UP to 1 IncL . . .. .. .._... ..._ - .. . . .. � FlNAL . ..--.. . . . -_.�.. .� . C� F�EC?R��R� Tq , Over 1 ta 10 Incl. OATE / /O�� VpLIDATION � "CoNracror Oate " ! � � � �Over 10 to 50 Ind.� ' FlNAL � V � ❑ 1 am exempt under Sec. ,. _. Over 50 to 100 Ine. , BY___. _ . _ _. � . _ _ w _..._. .- _ -- -- - Over 100 ' fl. B&P.C.for this reason .R. V) _. Services:Swbd.�MCC&Panelboards_-. . _. _.. . . . . .. � . ...__ . ..._ . _. ._. . .-�.�.7�2�'_ z —�-- -- - Oate: 0-200 Amp.Under 600 V � � � � ^' .. . . . ... .. . Signature 201-1000 Amp.Under 600 V � - � - - �- �--- - -- � �-� � ' - � � ��2 - _.. .. . ....... .. . .__. .. _._ __. . . Over 1000 AmP.or Over 600 V � � � ExemPtion for Reg.Maint.Elect. .. ._ _ . .... . .._... . ._ � .. . . I 8 S H 6 ... . _ _ . _.__--�- - -.._ . ..... --�-- `�� -'----- - -�-SINGLE FAMILY�-�- ��--� � Temp.Pbvrer Pole&Appurtenances • ' °&5 Z�_ . I HOME OWNER-BUItDER DECLARATION Sign with One&anch CirCuit � I hereby alfirm that I am exempt f7om the Contractor's License Law p�dnional Si�n eranch Cirwits__ .. 0 a 2 b—f3 8 for the foliowing reason�Section 7031.5,Business and Professions -- _ �-- - � � �� � � --� � � Codel: -- Misc:Conduits&�CorMuctors . . - . _.. . .. . . .. . ._.... �.. . . ❑ I,as owner of the property,will do the work and the siructure Other(See Complete Fee Schedule)_ � is rwt intended or offered for saie(Section 7044,E3usiness. _ , __ _ _. _ _ . and Professions Code). � CONSTRUCTION LENDMG AGENCY � � -�� -� -- - - - - - � -- ---- -- ---- - -��--� � ' '-� � I he2by aflirm that there is a conslruction lending agency tor the � � pCrformanCe o(the work for which this permit is i5suetl(Sec.3097, �pERMR FEE � --�- - --- - (Sub-Total) � ��� - � - - - - � ��- Civ.C.1. . PLANCHECKINGFEE __ .._.__. . . . . . . . .. . �.. . _.._ .....-._.._ ... _. . LeMer's Name � � PERMIT ISSUING FEE , , _ . _ _ . . . _�O_ O . , . _ ._ Lender's Address !^ . - I cerlify that I have read this applbation aM state that the above. TOTAL FEE ��7 � � . ... ... . .. ._ -- --- .. . . . informatan is Correct.I agme to comply with atl County ordinances � _ aM State laws regu�ating Electrical wirirg, and hereby authonze - , representatives of this County lo enter upon Ihe above-men[ioned --- ��- -� � -� �� � � � - �� - � � - ��� -- prop rty tor inspection purpo s SEE REVERSE FOR EXPLANATORY LANGUAGE _ � _ . . -. $ 2 2 �'�' _.. . ._.. _ . . . .._. .._. - gnaWre of Permittee te . � � , �•v��J�� �.•� -----f ' ' t.._.. .. . . .. _ , i � �_- --�= =I� ..I_ I...._.I.....__._-I--.�t...._.I.. __.-i-i -_i ` � ; I` I L' � ' ��- �' � � � I � . � -� �( i - � ; i I�= { i j_ r--� I `,.'�,, 3 : . - • I � �� ' �. � !�, - ' , � �' � = .,+ - .j j i I ; _I � 1- i _ '; 4 I i�l I � � � •�, � � � � � � - �__ _ � ( s + � ..' � � � � � i.i (` ; ; j � -- �-, , �_- � � -.i i � �j �r; ' i � '� � � i _ IJ ; � ...-. (_ -' '__ '' ; _ I` - � � I �_. � +. j' i j ., ` (`J I I ( � ��/ I' �2 T � T! 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