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HomeMy WebLinkAboutNo Permit Number (25) WORKERS'COMPENSATION DECLARATION 78A683 10/81 APPLICATION FOR ELECTRICAL PERMIT {� � I hereby'aR;rm that I have a cerfificate of consent to SB�F insury, CE-80eG . or a certiticate ot Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY L J copy thereof(Sec.3800,Lab.C.) � � Policy NO.�SR 01��Companyll�l OV STRI(}�. �.D. PoN APPLICAM TO FILL IN -� . .. JOB � Q ^f- ❑ Certified copy is hereby furnished... ., . , .EACH NO. . -.FEE . AooaeSS S �oo`�{ N't�'i�(j. �2 . . . . , .. New Residential Bldgs.8 Pools �� Certitied�copy is filed with the county buildirg inspection 7 8 2-Famdy,Sq.FL�_(__L� $� _ � S 'J LOCALITY S ..V � - department. �:- � ��,-n/ Multi-family Sq.Ft. CaDSS ST - � p., .Vi/�„ �Date q 3� o� ApplicanT-�m XX�'f Residential Swimming Pools � owNER oR � � � � FlRM NAME '(Y� E� . � �CERTIFICATE OF EXEMPTION FROM WORKERS' � p���y�s Rec_L'ght—Sw.— -- _ �.'( M^�� a� p `� �� � ���- -� ,CAMPENSATIONINSURANCE� �- � - . -� • 'ADDRESS�v S �L �7 (Thia settion neetl not be tompleted N the work involved by the Fret 20� permit Is for one hondred doitars($100)w less.) TotalNo. Additionat � CITY�S��. TeI.No. � 00 I certify that in Ihe pertormance of the vrork tor which this permit � � .. � �. a.nN Cr+ECK � � iS iS5U2d.I Shall f10t employ afry person in arry mann¢r 50 as t0 � . APRICANT _ become subject to)he Nbrkers'Compensation Laws. . L'ghting Fixtures Frst 20�!���- ADDRESS�- � - , .. . � -. � �, .�. Total No. � �itanal .. ._._ _ . . Date - Applicant - , CRY � Tel.No. NOTICE�TO�APPLICANT: If, after.makirg this Certiticate of Fixed Appliances Not Over t HP PERMiT -ExempCron,you shauld become subject to the Workers'Compensation , Range__Heater D.W. _ APPLICAM � F� � �C �� �.provisions ol�the Labor Cotle,you must forthvnth compry with such Oven_Dryer_ WM._ ADORE&S O � „� - - � ,provisions or this permit shall be deemed rewked. . . - . _.. __Top ._FAU.._.W.H._ . ._. .. __ � _. . LJCENSED CONTRACTORS OECLARATION. . . Hood—Fan _ Other_ ��TM IJ O � O� Tel.No: ��6�/ '�1 hereby atfirm that I am licensed uMer provisions of Chapter 9 . LICENSE OR -� Disp. —Roam Air Cond: -_- - � �� - (commencing witb Section 7000)of Division 3 of the Business arM � REG.NUMBER� d� 3� � � � -��-���% `(� pfpfessions COde,and my license is in full force�and ef(eCt. DISiAICT No. PRpCESSED 6Y _ � �Power�Apparatus 8 Large Appliances . .. , D. ��\��e � Lieense Num6er y R[ZO�3 Lic.Class ���b Size 8 Type HP,KW,KVA,or KVAR - _. ._ .UPtollncl.. . . .- __..._ ___. . . FlNAL `7 T Over 1 to 10 Incl. �ATE I}-I f� � Contractor-C/ECrR�C�l����� oate�T�. . ...� ... . 1 .. . .. vnuonnoN . _. p Over 10 to 50 Incl. FINAL �"" ❑. J am ezempt under Sca - � ��- � . ..._ 6ver.50 to 1DD Inc.__._ gy , . W 8.8P.C.tor lhis mason Over 100 Q� � �� -Services,-Swbd.,MCC&Panelboards�-- -� -�� � �-�-- ' � N __ � Z __ _ _ _ _ " Date:- 0-200 Amp.Under 600 V — s�9��c�� - zo�=i000 nmp.u�ae�soo v - -_ - _ �1 1 6 4 A ❑ � -� •� �-� � - Over 1000 Amp.a Over 600 V . ExemPtion for Reg.Maint.Etect. -.. ... . .. .. .. ..�• • • • •2 _. .� .-. . . ..... .SINGLE FAM�LY-�. ..... � � �-- TemP.Povre�Pols 8 Appurtenances HOME OWNER-BUILDER�ECLARATION � --� '�� - � " - '� --- �"� � • •9 6 2 6' �- � I here6y affirm Ihat I am exempt 6om the Contractors License Law Sign with One Branch Circuit for the following reason�Section 703L5,Business and Pro}essions Additional Sgn Branch Circui[s - - - - - . - ..-.. .. -. .- .. • e •9(z�O�� Code): � � Misc.Condu�ts s Condudors �� � ' � �----� - � � - �- � - �0�2 6-8.�. I,as owrier oF the property,will do the vrork and fhe structure Other(See Complete Fee Schedule is not intcrded or olfered for saie(Section 7044,Business . . . . _.. . ._... _. .. .�— , � .. _. . ._.._ .... . . . .- and Professions Code). �- � � CONSiRUCTION LENDING AGENCY - ----- -� � � � - - ---- � .. . . 1 hereby affirm that there is a constructbn lendirg agency for the � . performance of the vrork for which[his permit is issued(Sec.3097, pERM1T FEE-�� � --��'-- -�-- - - (Sub-Totaq- -gs� ? -- - � � Civ.C.l. . . . __ _. _ �PLAN CHECKING FEE. . . . .. _.._._._. . __ ... . . . __ . . . . � Le�Mer's Name . � .. PERMR ISSUtNG FEE. ... _. . . ._I(� O . _ .. _ . _ _ _ . . . Lender's Address �� ,� I certify that I have read this application antl state that the a6ove .- TOTAI FEE . � . . . ......_ .. _ _. _ _ . . _. informafron is correct.I ag2e to comply with all County ordinances � -- � �� � and State laws regulating Electrical wiring,and hereby authorize _ _, , . ,_ _ .. . .. . . ._. _ . ._._ . . representatives of this County to enter upon the above-mentioned - � � � � ��-� � pmP rtY for ins ection P�r� _. _ .__. ..._ . . . _ .. _ . . . . . �SEE REVERSE FOR EXPLANATORY LANGUAGE � � Signature of Permittee � �te � � �!�. _. ..�._ __, v�,,. ' j���! (-r' .,I J f_ '`..I.;.__1_.._..'I_�i - ��I � I I _ - - ; �I' � I� I I I II ' i :; i i '��•_ 4 1 �� j � � � ; � i � � ; ,. � � , -j i �_ , � I I �j _ � � � i:._ � ' � ,; i ; - ; i i Ji ; � i , ' � t ' _ _ � �r � � I � . I � _ t . f` I � . 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