HomeMy WebLinkAbout1574A WORKERS'CQMPENSATIONDECLARAT[ON ' 78A663 APPLICATION F4R EL�CTRICAL PERMIT ///���
�� � - � � CE�906G 12-801 �
[ herebv afEirm thet I he�e a certificate of consent to sele COUNTY OF LOS ANGELES BUILDING ND S FETY
insure,or a certificate of Workers'Compensation Insurance,or �77c� ��6� ��
a certified cnpy ther of(Sqec.3800,Lab.C. ��+�6�
+ Policy No. 7Q�/Co npany J FOR APPIICANT YO FILL IN �pg �/D�� � �Cf
� New Residentiai Bldgs.&Poo�s
EACH NO. FEE ADbRE55 g�'/�����
� � C �fled copy is hereby Pornished. 1&2-Family,5q.FL a — S LOCALITY ,,� �
� � Multi-family Sq.Ft. N A T
I Certified copy is filed with he county 6uild' nsp ion CROSS ST c�
� department. Residential Swimming Pools ���WMER OR �i1,
I Date��pplica � �1 I \ F�RMNAME /1�
Outlets:Rec��light�BwZo a7�j S 7 qDORESS � / �' es /i/
� CERTIFICATE OF EXEMPT FROM WORK£RS' Total No. � Additional
'i COMPENSAT[ON INSl1RANCE PLqN CHECK u Tel No. �
(This sectlon need not be rnmpleted if the wock imolved �;� '� APPUCANT V
' b Lighting Fixtures First 20
y the petmit is for one hundred dollazs (5100)or less.) ADORESS
Total No.� �ditional O
1 cectify that in the performance ot the work tor which this Fixed Applianees Not Over 1 HP CITY Tel No.
permit is issued.I shall not emplay any per�on in any manner PERMIT V
so as to become subject ro the Workers'Compensation f.aws. Ran9e�Heater_D.W. APPLICANT ��`i � �� d
Oven _Dryer_W,M,_ ADORESS 1 � � � r� �� Z
' Date Applicant Top _FAU _W.H._ L —
' Hood_Pan _Other� CITY Tel No . �
NOTICE TO APPLICANT:IF,after making thia Certificate of Disp. _Room Air Cond.__ L+CENSE OR- -
Exemption, you should 6ecome subject to the Workers' REG.NUMBER 7�C1ass C�
Compensation provisions of the La6or Code,you must forth- Power Apparatus&Large P.ppliances DIS7FifCT NO. PFOCESSED BV
' with comply with such Drovisions or this permit shall be Size&Type HP,KW,KVA,or KVA �
deemed revoked. �
� � UP to 1 Incl. I �
Over 1 to 101nc1. FINAL
� G[CENSED CONTRACTORS DECLARATION DATE � VALIDATION
Over tOto 50 Incl.
p i hereby affirm tfint[am licensed under provisions oP Chapter Over 50 to 900 Inc. fiNAL
BY
� 9 (commencing with Section 7000)of Division 3 of;he Busi- Over 700
ness and Professiona Code,end my license is in full(orce and . ..
effect. Services
G� 0-200 Amp.Under 600 V
� License lVumber � � � Lia Ciass �`-7 ��.���p Under 600 V
i Contractof�S �F . Date�� ��-4 / � Ovar 1000 Amp.or Over 600 V �
� :�i 5 7.4 P,
HOME OwNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �
[ htteby aff'vm that 1 am exempt from the Contractor's Sign with flne 8reneh Circuit �• • • • •2 .
License Law Eor the foliowing reasun(Section 7031.5, Busi- Additianal Si9n Branch Circuits ' � • • � �',7 5
ness and Rofessions Code):
Misc.Conduits&Conductors � � � � g�5`
� I, as owner of the property,will do the work and the Dther(See Complete Fee Sehedulel�
structure is not intended or ofEered tor sete (Sectian
'I044,eusiness and Professions Code). I O,2 C��7
CONSTltUCT[ON LENDING A(3ENCY
[ hereby nffirm fhat there is a construction lending xgency
for the performance of the work for which this permit is pERMIT FEE (Sub-TOtall
� issued(Sec.3097,Civ.C.). 7 Jr
Lender•s Name PLAN CHECKING FEE (One-Fourth Permit Feel
Lender•s Address PERMIT ISSUING FEE G �
1 certity that 1 have ad is ication and state that the TOTAL FEE l 9 5
abov � armation i orr t.l e to comply with ail Coanty
o n ces and at aws ulating Electrical wiring, and
er euthor' r rose 'es of this County to enter upon
th a ve-m d pr rty for inapection purposes. SEE�REVERSE FOR EXPLA�NpTORY LANGllAGE
/ /a d"/�/
Signature of Permittee Dete �
iy , ,... . _. .�_� � ;,
- - � , ,
. . . ;
,,., , _
. .,: � , � � ,; ,
. s' . '. � ��, ~' , � -i
. _ f .-1 • 1 ' ' . � �, . �. 1 ' - �
. . M .( � !�. i ' � 1 . ^ ' : i.. ' , ` ,
_, i � ,
� _ _ - . ' � Z � ,G O �i .`>, 'p Z 7 . '
� -{ �,iC x G O .
v D
:, O ; '[ t�. 'C' Z �" 77 z �°
1' m r � � _ G� � c� .p � � • --Y
u, , •n r. � ..
�' � , n C� t�i� 'O ➢. r,' � .
i O � � p � .� „ ,
O C � trn
� _ � fl i O O � ,
H � ['
_ • n r T m
i -� , m �
, �. - � � d• � . .
� � . . -
- . Q_ /� - , D �.
_ .• �;`� ,. .." F
.. � �V ,. ' ! '�,I., _ �i
,_ � � ' ' '� �_ .�. � . L�Z .. .
-- _ 2 n '
. , : _ - - � � " r-t�-i
- - " co ..
, - . , mA � .".
, _ �
11 � '
� � � r
' ' / .�
' , ' - . �I ' .. - . � �
I_ � '
' � '_
. � ��� � � '
�1 -
. ` . . . .. . . .
�� ,
� _ 1
. .. . - ..--.. ._. .. � •
• ' �
, ' .� , ��`.�Z�i'���...�O +r'.�� •n� �
1 ' •. '. � ,� ^ " `':� C ie ^ C r0 'C L n ��� �'
� . � p n .7 n G ~ y^ 'b�,p� �.�? =_p �C "e�"r f�. � �
, . L`-�,C T. � n U n !� m, �n ..",�N 7^". '�'a i.�' � h. L". .
� .. . . .. '.� � . .. =b C `�(�'_ � O C y C '^'C :. ec r`� i
'C'.�,'C �:� � � '� V C �''S '^ � : ~ %�q '� � �' � Z
� � • " . r � v C ,�o, a. C Y_ tn'O n G.,»'C:" o '� 'p � ^,4� �l ["� .
`� ~,ti 1' v, � �,+ �
h
. , • 'O � ?° � -°-�.o'�.Q � � r. ��;';, c �p �q�� _ ,��� �°� .���..
' .�t.. .,� �C � `E .. � =° " �� ? �v:. _.c:1�:.n a.'��'=.�� .0 -
� . � � ' . � „�D.� � C7 � .^' �., r� �� �; _•C .�'. M :i�-'�N— n�.� q �"o N•r�'. � ^�
4 D
. ' - C ,� , �� c � " N�"y � ^�^ voo `�V4�� - c �y C� .
� G �
. . • - ' .. . , �t � = = '� C �- f^. .R-•C^ �N �� N �.i y G . ✓ .
� - ` - ' . - i � - ^ � ���..q « q� p,� q p . �� O•� n.^ � C n� j � .
. . � , v; � = � _m� �� a,�.� _�;,4 n.. o �; � ry .
. � . , n� „f�t .. Z� � C.t3 ��"�`,�^O �� _r'..`�C `.0.O'^--:i � p���� ? C�
, � .. . .. . . � � K ., 'O ,� =O �p � ' � C7
. ti, v, o �G�0.c o � � o �c o t,.' N N .;` � r.,
" , . ' - � _ ' • p. n � "c.'�',�° o��h � � �G '_�4 c.p o.^ � n b�� s-'`& G �
. ; - - � � � ��. '� � ;,,�.o A- �d,�o�'^. r' 0.=o�Cr.;, �
� . t ' • �� � C..`~_ e. i;'O c' �' '� 'e ^ '° „s, � ' � � ! .
. " �r. .`e .-.A�C7 1i 'c ^���R= i r-�
• , ' � ; .. . _ . .. . p �_ :� � C4 .C7-C O �q k N.b:�� ��i0`e -• n .�
. ' � .. .. �� _ ' - .. n �� : C'.�.. . 3 ` � rc O�-p. '� C � C '�
, . . . . " � .... � q � n � � ..O..�" .... �' � " : ^ .
- C c'o� �; • �`, _'� 9„a ,,,��i!'�� c, N'3 n �� �
. , , . _ . � io � ' p `,l C o C� 'ci �c'C O w r.
' . . . - . _ n i� 'o O F, - O �� � k C'C O�c ti c ,,,,p ..
' ' - ' ' _ .' ' o C� `O 1 C L' �'' Y �^.� 'Y� .. t �.� f^,� i>�: :"v.
;� ' . . :. -- - -. � i, ;c �' c` u n " 'y ;.� `o`° n
, .. • � . _ _ ' . ' +�^ �•. � O..�.. G "
' . . . ' . . i� " �+,
I