HomeMy WebLinkAbout5451AC!C'7KERS' CO'-!'ENSATION DECLARATION
rr Y!rm that t have a cpr:i'ic^!o of consent to se'f ins -we,
ce. n rl l';orkrrs' Co^ronsatirn Insu^nce., or a eerlEod
No. Corr; nay
C.v!'Ipd ccpy is h^-eby furr:9,ed.
Oertif:-d copy is f; -rd ::!!h the ceur.!y building inspection
dernr!ot.
Dalc
CERTIFICATE OF EXEMPTION FROM WORKERS'
CC'.!,-Et!SATIO!J Ir!SURA'JCE
This section need not be completed if the work involved by the
permit Is for one hundred dollars (5100) or less.)
I certi!y thzt in the prrfrrmnnce. of the vn-rk !or v;hinh this rormt
IS issued• I shall not emp'py aey pe,son in any mangier So as to
become snb:ecl to I-IVarker;' Cempen=_=_;D ion/Ln::s.
10
NOTICE TO AFFL!CANT: If. af!cr m.:4i.n3 this Cerh'icate of
Exemption, you Sho:rd t' tome Scb!ecl to the t" erkers' Cpmrrnsetipn
prcvis;cns of too L.-bcr Code. you mcsl forthwi!h ecTo'v v:Ph such
pr0c!gions Cr t' is R.9r^--t 0,11 be dev—d revoked.
LICENSED CONTRACTORS CECLARATICN
I hereby !""'n l ! I nm '-ens^", ccd-r pre':isinns of Chapter 3
comm^meg wd4 S 34 is! len 7000) or 1on 3 of the Bus mss and
IdPr0!CSs;0^5 Ccde, .-Pry Fcen o is n r:!'I ft•ce end c"ntt.
Liconsn Number
Cen!rnc!-r
I am exr-,,t under Src.
DBP.C. for this rraspn-
Lic. Class
Calc
Dale.
Exc .. cn 'er Rng. f.'- it. E!ec..
OLE FA'"LY
HOVE CWNE R-RU'LCER CECLARATIO'J
I hereby a!firm Ib,^.I I ,9m" 9m ex^^rt fe". ! e Cormicto s Lit^ c La:-,
for the 1n!'n ..,g r.. ^q IS^c. en 7031.5, 2.:c ...... a7d , „ons
Cede):
Q1, as c— r of the, r'operty, wN do the week and !hn sducture
s net n*"d^d or o"e•ed fir s..a (Sec!;'=n 704-1, Sjs;ness
and Pre pssines Code).
CONSTRUCTICN LENCNG AGENCY
I hemby rf'rm !Fel there is a eons,Iwclion lending agency for the
perforrriece of the work for which rois permit IS iSSpcd (Sec. 3037,
Civ. C.).
Lender's Nnme
Lender's A.d^.•ess
I eert!y that I Mve re.n.1 th ar?'ic,n!ion ands c that the .bove
in'prmn:ion is correct. I ,eg-r.e to comply vrth r.!? Coun!y ordinances
and S!=!e In,s no3'a'2'ing Elcc!riral wiring nod h.^-by •nuftrizc
rep'esen!n_ti`-is of Ih5 Co!mty to enter ur. n the above-menficned
property for inspection p''rroscs.
ne.,r
7FAe.F7 !Drat APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY/r r, -d-
FOR APPLICANT TO FILL IN J09a^^KESS` b y r LL S
Nov, Residential Mons. 8 Pcr.!s EACH NO FEE
1 R 2-F,—i!y, Sq Ft. S — S LOCALITY --D' 0
f:_:•PC S7
CPOSS ST. /r -,Tr 1 rH ,+ Mu'li-family Sq. Ft.
ResbJen!i31 SN—:no Pools It ON s 1F1r,:.f I!A!C S
v r •
ADL?ESi 11 ( • 0L JC'IL. Ou!l(,'s: Rec_ Q;ht _ S:v. —
Fiat 20
Tc!al No. Additional CITY Tel. No'7(Q-gid_ j
PLAN C!Q'(:k
APPLICANT
ADDRESSLigh1:n3 Fix!u•=s First 20
Add:!icnel
Tc!aI No. CITY Tcl. No.
Pixod App':antes Not Over 1 HP pt-wprl= A MY A- S A4*0,ir. Ra^.nen_ Wnfcr_ DIY. Aee•+N!!^.T • P
CDRECS ( ) ( .S,)L by?, mye' — tYaa _
Top — FAU _ WH.
Hood _ Fan _ O!hcr_
CITY
O.sp. —_ Roorn Air Cond. PEG t!L CIi CL - f:LT+P-R
CaI1rCT r1U / `, f":JCCSSCD KYPowerPowerAppnrn!us R Larne Ap, li3nees
Size R Type HP, Kri. MVA, or KVAR
V
Up to 1 hpl. FINAL
Over 1 to 10 Incl. DATE rJ VALIDATION
Over 10 to 50 feel.
ra1AL 7
Over 50 to 100 Inc. n
Over 100
Serv'i..rs. S.M. MCC R Pnoelbonrdq
0 - 250 Amp. Under COO V
20 1- 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp vror Pole R Appurtenances
n vn!!i One. Ranch Circuit
Amwinn l S ;n Prnrvch CirCtpIS i • • C_ ;, „ .
M sc. Condu?s R Condoclprs
Other ISpc Co^,^.Ie!e Fee Sched-,yo) I; 'J. 1 C — " O
FERVIT FEE (Sub-Tc!al)
PLAN CHECKING FEE
PERMIT ISSU'."JG FEE 0
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
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