HomeMy WebLinkAbout1427 (8) 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�P�� J FOR APPLIGN7T0 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 � � ,.4 . s � m'O u ` ?= Gt"� � _' w � ' d C o �^N �'l7 � p G� �N C 0.� p p N D N ,'t'.. ' t Y'' .n V M � O� � O-� ii �' � O Q¢'O c� fl-C C� � 1 � ' O '`L^o O N �� �+cn s L r O L �d u. p ' ;): , M „ H C t � �l �L m O � O O � i o��m�' � oCDcaNt? x � c3 ' o,oa-O ` � c �v�mQ,Nm No p3� c v°ro�c am o° �S ` f U ° $ �:c o p E a� a o�s s�o V o � � 3 °' � ��t u O c �n "' �U - O �'�� � a� m � 5 m � $ ` ° ; c � c .L.c m�O '�' L) ��� �'� � �.��. Bi"j d�> � 7,m O � �' ,.,: C '.a U,`�, '� ` ' •, � � E Q�am m E O ��n�N >' : N- Q.n �_ c � E o " - � o � m� co.� qo� $�yo " � �, ' d=� r � `. Q T � Q o 0 oy +- �n, o � "" d ��' QE� � � � c am0.p �'= `" �� K. w 1 c °- $°�'v� x °°o y�s'o „o�°� .°c > '.,-�c� �n `,� , ;' �s� E ts m t,' c o � 'poc �;u` ¢'? a�o "-' E�n ° � �� E a m w % E � - s � ' ,�F O �p cc �!M n-' >� x" � � o � 3. ra."'. �, �" � .y I � � ° o � �y cr[�o �' �°� . 3m ��' °� ° �� O x�: U � d 3 � o s a,�"�o,`�? m n.c, �a> ci� m`° 4 ir E..°a E .�n� �'. o' E c O CL� s p .Tn- N;, o x q� ,nr+ Q ?"� �,��sv p m� � 5�1� °b , O �r o n-�` -AG.u �n o f n a��w �a� ��n � � �c o!� A cn � �'�G.=� �'c �n p ��� '"� ;n �:^ ° e � v �o �' a� p X�.e''r L Z i: C lJ � O p N o� 3 C ._ a ��.. . , � N y�.a O O N C p � , .>, d G..�m C�v n ya Q �'C � . t+ p �� �- �,�' ? ' Q Q� „"�.' �`n N ..` . � � � N p tiT� �{ s_ m , , �: � J a •".' ✓ � • � '��4 � � ` �! f � t � '� � � �� S � � �� � � � � � � � �1 ��j �� t �1,� � � ,, ' , , � � 1 � . � �:, �4 �`� '` � �, ` � `•� �`t�; i� � ; ', ��s . `y � �',� '1 . �i .i e � � �� 9 �j � t � � � � ;S ��, '' 'l '� � � 1 � ' t i. ,�y, � ''t �, `� � � . w ��'�`i _1 � + � ,i � 1 j Q � Y.� +. � � -.� � �+ �ti � � t �Zr 1 , 1 � ; 1 1 � [� `.�i v � ---' � � � a t � � in �.-r•" � �a.� � ` � . . . � �' ;� � � 1 E �, � j ��;,� `:� , t ' `I':, ' , � , . '' '', `�; �``', + `; ,'� iS ` + � { . , ,` ' ` '� ' + ` N� ,\ ,t� ` �ji `� � �' '.{ .��` '�,��` � ` } ��� ' �.�1 ;, ' + ,. � � [�1 1. t v. � �� � F �' ��� , � t ,�.,.---"'.......! L 4 � �,,'. � e'1 �i � . j + 1 � 1 y. V1 ^i��; �'�w�,'� 5;.-. � '} � ,` � '` '� � ,, � � ��'��^ j' p t,'� � �'j �. � t. , ..�g� i � �� ui.� � '' ` i `"� ''t 1 y �x.. ,, ! � � i � � `'.; �,�'' �� .r ' '��' ��S ��` � ,, '��� t ` , '1 k � '�'`,G`�i�`�J� �w '.`•�� ' •`� �ti. � _ , �'� . '�� � ,� ,4 t ���' 6.�Y�.�'�; .- .t_;;p d 1 ..� ,'.) i� � t i � ' � � 'i �� ��� 7'. �. ��,:' ���-d l.) 'i n �C� �� , t; i �' �� � j � � � t i. L�•'�^ >"' � �� 4 3�" ',1 `� T�. ' � i �,, 4'+��� , � �.K7 �'�1+'.;. �. ,Z- C� •:t :, �"� �1 1 , �:��;-��..�-�z.' .� Y � � . �',.• `� � ��`, � � � � ��; � �`', ; �':��� ;. �: �r� u 1-`"� �,'�'.Ov.�">-L""., '�,'� � � � ' `1_ ` � � � � � 'r;-`� < �.�:�..-'�'': �'-= ? i � � 1 ! � . a �� � � � � ;, � 1 ,•. ,-�,'`.:")�:-- '' ' �� ' t , � ',, �tt . � � �•� �f+ .,y � �� 4 � ,j ,\ � '1 /'' � ... `� 1 j ; - 3 � sj i �'� �*J y� ' ...� ,f'� �, _ � � .t`,4 } �' � � � .� ..� C' �` .. 1 t s\ � ' .�, t' � '�.'��'�' ` . ,`J=, i � ' ' s- y� •� .. ___.�.- _r�,. '^ '_/�" �