HomeMy WebLinkAbout1427 WORKERS'COMPENSATIONDECIARATION ���p� ���g� qPPLlCATION FOR ELECTRICAL PERMIT
I hereby affirm thaf i have a certificate of consen�lo s If// �'�j�'
insure,or a terilfico�e of Workers'Compensa�ion lyf�anc�/ ,� COUNTY OF LOS ANGELES BUILDING AND SAFETY �`
or a certifLied copy thereof(Sec.3800,Lab.C.) 6 �� 1�� � �T b LI
P❑olicy No?��ompany�f&_1�i1�D_�� J FOR APPLIGN7 TO Flll IN �OB
Cert�fied co is here6 f�rnished. EnCH NO. FEE Aooaess Oq E.Q1SD�1L '�U/.�
PY . Y _ .. . . ._ . New Residentia{Bldgs.&Pools .. - �
et&2-Famil fi. s = 5 LOCALV7Y D�A .,�� .�4Q
Certified COpy is filed with tha tounly building inspec- Y.SQ�
tion depa.tmanf. . Mul��-fomily Sq.Ft. NEAREST
�2 ���" Residenlial Swimming Pools OWNER OR ���� � ���LS �D •
Da1e Applicant FIRM NAME W•LYQ� CO.
` CERTIFICATE OF EXEMPTION FROM WORKERS' MA�L /�
Outlets:Rec_Light_Sw._ AOORESS
S COMDENSATfON INSURANCE P.O. �Ll I
Fint 20
( (Thia�«t�on m�d aet b�eompk��d H H�e work inrolv�d by Total No. CITY iel.No.b� j
( Nw pemEG Is Eor ww kundred doflan(SI00}or IessJ Addi�ional 6td Oa�•`��i00 �
1 cer�ify ihot in tha peho�monce ot the work}or which this p�ppN��TK
permil is iss�ed,7 ahafl not emplpy any person in any manner
so as to become su6ject to the Workers'Campenmtion Laws. Lighting FixWres First ZO ADDRESS �
Tofal No. Additional
CITY Tef.No. �
Date �pplitant Fixed Applionces Not Over 1 HP PERMIi
. NOTICE TQ APPIICANT: I€, afler moking this Certificate of qppLlG4Ni G .
E:emption, you should become subject to the Workers' ' Range_Heater_D.W. _
Compensation provisions of ihe Labor Code,yo�m�st forih- Oven _Dryer _W.M.— ADDRESS 0
with comply with such provisions or ihis permit sMll be iop _FAU _W.H.� �
deemed.evoked. Hood �Fon _Other_ CIN a�� Tel.No. ,�
IICENSED CONTRACTORS DECIARATION �
I hcv�by affirm thot I am licensed under provisions of Chopler 9 Disp. _Room Air Cond. — R����ER �4f� Ioss, C^�Q
(mmmencing with Saction 7000F of Divisinn 3 of ihe Business DISTRICT ND. OC BY R �
ond Professipns Code,and my license is in f�ll force and eHed. Power Apparatus 8 Large Appliances � #
Size 8 Type HP,KW,KVA,or KVAR � V �
License Num6er Lic.Class ��1 O Up to 1 lncl. fINA1 fY j
P ��,� Over i ro t01nd. DATE �=/le� ��5� O j
Contract �l• �����t_Date r�s�� VAUDAAON I—
� � Over10to501nc1. FINAL '�"/Y�7 W �
i am exempt under Sec. Over 50 fo I00 Inc. BY �- r:. 4 :.a .n j r n.� �
Ove�700 N '�
B.&F.C.for Ihis reoson , y �i ;:, z
Date: Servites,Swbd.,MCC&Panalboards � � _ �� �
0-200 Amp.Under 600 V i r �! i -� , �
Signature � 201-1000 Amp.Under 600 V 4
Over 1000 Amp.or Over 60p V � 3
� Ezemption for Reg.Maint Elect. t yµ��p�f
SINGIE FAMILY Temp.Power Pole 8 Appunenances
HOME OWNER-BUILDER DECLARATION Sign with Ona Branch Circuit
I hereby aHirm thar I am exempt from the Contractor's License ,qdditional Sign Bronch Circu�ts
law for the following reason(Settion 7031.5, Business ond 'g yu� a0�
Professions Code�: �
❑ I,as owner oF Ihe property,will do ihe work and the Mist.Conduits&Conduttors �
strudure is not in�ended or offered for sale(Setlion Other(See Complete fee Schedule)_ �
7044,Business and Profeseions Code).
CONSTRUCTION IENDING AGENCY ,
I hereby affirm thol there is a mnstroction lending ogenty for ,
�he performance of the work for which Ihis permit is issued PERMIT fEE (Sub-Total)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
lender's Nome
PERMIT ISSUING PEE I O Q
Lender's Address
I terfify lhat I have read this applica�ion and stafe thot the TOTAL FEE �Q�•S0 -
above infwmation is corred.I agree m comply with all Couniy -
ordinonces and State laws regulating Electrical wiring, ond
hereby authorize representotives of this County io ente�upon r
the obov - eni" ned properiy for inspedion purposes. �
SEE REYERSE FOR EXPLANATORY LANGUAGE �
� /s-3-�S' " ]
Si arore of P mivee Date � �
'.F .
1
d,a .
�L O p�� -
u � C
� ._Z vL � d N � [ c t
mTN No��, c CONa� o n
. r. ,ri v r d 61'C �, O-p v p C � V C.O N 7 N ,- �-.. �
�p G�N C1 t � f1 � C� a� m • �
�e'/ 3,�� H'V '^ C a ^ t tl } m ix- O O � .�L..'EO y D ' .l, �
0� L'EN'O 6i O C, c�O N > t`pYi C.� y � O 1" I
C D t ��-_ > 0.0
OOp�'uN> Er � pm9 ���j �GG.� O � �'�l
V � � �':aoQEe� po�-� s-oV � O E � ° c
m c� � � 5 m a° � w o N "' a� �, ° - o i-¢+ �- ' ' /
'�` Y N o ��,,,_ y`",.� a � � a 3 m c o c�,c r. m`o �,. - � .',t
:r � � E�' p'.�i-'Pm m E o �� a >p'�m �Y o .a n 4 '-• � :
ifi O O T ' � Q y N .t.. c d C 4 O w G-� � Gi c 4� �� v.� G '+` '��)
� V a. �w oE�a� Q� oo ° .°o � ° - so:�r' •. �, n
'��j' a � � �.so � c .. � $'m0.o � « 3 ��°. � � �} ' .
�_ % �4=[�?V � x�'�.e' O ,C �C m O�""'O „6C b 's;C�7 �n ,
�� � �� N C'y 6-a O � � �� O G M O Q. > C N� t?. '.� � �f� ' ,t ,i
p c rCai ..'m� rvcuc+ �,ti £ O a w3 � 4
� c p L x:= C � O m a. C1,;• � �
�a O u ,��„C C C;Q � � G1"t7" .. 7i .n� ..s O� a G'�C, p a.� t � �
� o s a�� o u .r�,o x m �,'i o m m� r� � n E'�'a x. U 1,� a, 3
�, � o �'��N:.; fl � � u� oa.� c E� �'� �., �� °' c O
�'l:. �aa a� r,�i�a ow �'va �,��rvo �+�u, ��� °� Q
�, .�.�.�'p s �^.� p a � �r.... ` � �c�.-�, O m
t-5,�^ � � w'�'q,� +,'F6aNY"'•-- °� �yc; � ` ` �'° �=
' ymm�..�mc�," � `'r'un,a� ' ' ..
�t� w �^ c ,�, � ,, o d . o r, .,
. � u �� C O'�U v� '^�°" • S�
_ jm , i
J'.
�• `
' `� �
V�, {
� 4 � i 1 {
� t � 4 � � 1 ' � � 1 i
t �� � ';'i � t � � A� � '
� � ! `C (t '� ' ; � � i � � ; �
. •-� . 1, '.:t ;� `� ' � V` t F� , � �,:� �Zj �,� 4�
� � �'� � �s ;� `, '`� '� � "� � •` � �
. � � � � �'�;lt ' � ��t ,st �'i�; 1`i ,4`�t .;1 4 l � '}
� }}} .k
�Q � ' '',, `' r',�. �� �` • `
ra ,'a i : . ' � '1
i �� � � .�---'� � '� � . . � ', } � {4 i �i
. � t 1 ` � ' � , . ` . `� � . � �'�.
� � '�� � 1 ' ���1 � �`� �1 �a � 1
� � �`. ' �
,� � ;4 �; '', t ,,I . `y i i 1 �i
� C i ` . , i ' '''�� t i i
�["i„ +'� s� 15\ � �.i 'i �`,� ����..���� t_ . � � �j � '� �1 i y` ' � i
�' � �' ...1----'b'"'"�� �t � `,'-. �l .. ',� t'1 �� ''t `t 1 `�
�� _=+--- —..'} �� �w'. !1'F.: � ��� �! y �`` , 1 S � � `�
1 `� _{' � 4t � � � t� ;' � t ' ; `' S
t � 6.. q j `�S ` � �, t ` ., i
' ��,A i. �
� j` � .Pd ;,,;4 ":,.� .'�'� r�t. ,i. �� { '� ! �{ ,
;1 'J.t � Y', �v � M � ' 1 �i ` ' ' �''
'r t)t �.�7 �•': , .� F.. � �5 �1 3e� � ,i
�.{�� ��t-o ��- .*� Q •:. t v \ ;
�.S (, �.- cP:t C�"�:� Z.:� ��-<L � li i� •�� . �; ti.� �'t �t l �1 t,. �l � ,� '�! 1
4 a' ������ U„�`y S*% '.�, � ;,'{ � ,,1 � C: ' '' . 1 � � � E i
,Zt 1 � �
t,,,,;. p.Y �v � '` .:k ��� ' � g t t
'„:�a�! �•, L.� ry r-,� O���u.. 1 `� � r.• '' � ',�� ' �� ' � : � t � ,k,
;z C.�� `�.X".y ��i,� ., 1�� � �
' '�',s,�Z � 7�'�_�,•- ','`�'' t � ' , `�r� ,,'� i
•^�,'"-1.:�� ".1=.. �- �;" _ ik � � i � `�� ��' 1 � � �
�4� ('y �l• 1 � � , , � k
f
...� .-+ ` � �'.' ���` 4
:�"' �� � ' � � �� � � � �� � �� �� ��
;,( '`'_ :yi r; 1, � - f l . ,' , � � ;� �
1 :", �;� � = t � l .
.� t ' � '� y � + /
i _� �"-� ' �
!•' ( C T
. a... _. !� 1kF �'s• 1� . .
,'�1 ,r,: ' ,
. ' �l•'
� ,3 '4 , ,
_ ��_.�'"
-�"'
�,