HomeMy WebLinkAbout1531A (8) ! . ;` .
WOFiKERS'COMPENSATION DECLARATION 76ne63 tv87 ;
� CE-806G QPPLICATION FOR ELE�.�T��C. L PERMIT , . �
I here6y affirm that I have a certiticate of consent to seif insure, t � � - : � .,`'h � e:H:• i
or a certificate ot Workers Compensation Insurance,o�fied COUNTY OF LOS ANGELES � � f��1�C'i A� .�S/;}FETY i � °5� "� �
copy thereoi(Sec.3800,La4,C.) � � '
a�o�xY k . �. ;
Policy No. Company� FWt APPLICANi TO FILL 1N � �
❑ CertiFied c�e6y furnished. New Residential 61dgs.&Pools EACH NO. FEE ��E55 2!o Z3 J�` n ✓✓1 ;
1&2-Family,SQ.Ft. � — $ L O C A L I T Y q�
�Ceitified�copy is filed with the co y huilding inspect� _
deoartment. Multi-0amily Sq.Ft. NEAREST /
Cf105557'-- Lr
Date�_Applica Resitlential Swimming Pools _ p�y�p pp
FIRM NAME p✓)
CERTIFIGATE OF EXE I FFOM WORKERS' � L � � � � � ��L
COMPENSAT NSURANCE Outlets:Rec—Lighi Sw.—
nooriEss
(This section need noi 6e completeQ'rf the wak involved by the First 20
permit is for one hundred tlollars($100)or less.� Total No. Additiorel Cf7Y Tel.No.
PLAN CHECK
t certify that in the perfarmance of tha worfc for which this permit APP�iCANT O
is issued,f shall rrot employ any person in any manner so as to
6ecome su6jec}to the.Workers�Compensat-n Laws. Lghting Fixtures First 20 � I ADDRESS .rj„Jyv
Additional
Total No. CITY Q � Tel.No.
Date � MP���a Fixed Appliances Not Over 1 HP
NOTIGE TO APPUCANT�, If_3f ._ flwking,this C ifirate of PEFMI ��
Exemption,you should b2co � iect to the Workers'Cort�ensation Range—Heater_ D.W. _ aPtticnrvT �'
provisions of the Labor Co ' u must forthwith comply with such Oven_ Dryer� W M._ AOORESS �
provisions or this aerrNt sha I 6e deemed rewked. Top _ FAU _ W.H._
LICENSED CONTRACTORS DECLARATION Hood— Fan _ Other_ GCFY Tel.No.
I h e 2 b y a f f i r m t h a l I s m l i c e n s e d un d er pmvisions of Ch2 pter 8 LICENSE oit
(commencmg with Section 70001 of Division 3 of fhe B�iness and Disp. — Room Air Con d. — REG NU�BEa � � c i a ss. f
Professions Code,and my license is in tult force urui effect. �ISTRIC7 N�. PROGE55� � �
Power Apparatus 8 Large Appliances
�'/f y Size 8 Type HP,KW,KVA,or KVAF m �/�c R �
LJcense Number J"d��P Lia Class �_Llp to 7 Incl. w � V FlNAL �+
S ��' _ ��sL� �". Over 1 to 101ncL �ATE VpLIDATION Q �
Conhactor Oate Over 7�to 50 Incl. !
❑ FINAL �j i
I am exempt under Sea Over 50 to 700 Inc. BY �
Over t0o �
8.&P.C.for this re:aaor tn
Services,Swbd.,MCC&Panelboards � ^ �
Date: 0-200 Amp.Ur�er 600 V _
Signature 201-70D0 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V 1 �
Exempti f eg.Maint EIecL �{ ��� � J
SINGLE FAMILY Temp.Poiuer Pde 8 Appurtenances #� ����2 �
HOME OWNER-BUIIDER DECLARATION Sign wilh One&anch Circuit
I heretry aflirm that I am exempt from the Contractors License Law '� •t 2�,Q Q
for the followin reason Section 7037.5,Business and Professions +��tpnal Sgn Branch Circuits
y i ••i2�0Q� �
Code):
❑ -- Misc.Conduits 8 Conductors fl Q.�3-`'8 4 �1
I,as owner of the property.will do the work and the structure �
is no�interxied or offared for sale(Section 7044,6usiness Other(See Comple�Pee Schedule)_ �
and Professions Code).
CONSTRUGTION LENDING AGENCY �
I hereby alfiim that there is a construction lending agency for the
parformance of the wak lor which this permit is issued(Sec.3097, pERMIT FEE (Sub-Totaq
Civ.C.1.
� PLAN CHECKING FEE
Lender's Name
pERMIT ISSUING FEE
Lender's Address
I certify that i have read this application and state that the ahove TOTAL FEE �
information is correct.I agree to comply with all County ordinances �
and State laws regula4ng ElectriCal wiring, and hereby authorize
representaCves of this Gounty to enter upon the above-mentioned
property r inspect�on purpa�s. SEE REVERSE FOR EXPLANATORY LANGUAGE
� �z�� �
gnature of Permitt e Date
- v�, a �� $ m � .c h � �._ � y � b �o `m
- �O "3.:� � r� �o = �' �
' v '� � �Q ,� � o � .� � c� � � . ...
� � ,4�' a b' � � ��', o � `� �,' c � ,
a`�i �o�� (7
" � H $t' yy � � 'yu� S .^x..- U '� � � � � ,I
° ��y5 4� E .�M v :o •
w ��?7
�� � "V � � � � S � �p.0 ,� L C N � ' .
k- � �!C � +'N; .__ .
.•'Q � PS v7 E y� �Z„ t� O �„G• O Y p s .
^ t y
�;�a 'Uo 't'� �°� � 4 � ob c; °- 3 �o �Q
Y � 3 `�,, �� � ,� ��;;a Q $ 0 3 o y � � y, •
w � � � g � yo -" $�.r � � � � a =' t4� .., .5 ;.
� p .� � ,c � r U � � � � � 2'a o � y ?' c � � ,
'..� " � U .y m c � s c� � � � � '' �
9 �'�` � �.� :� �'ot � ya o ,��' ,�''" ,'b � �' ' � r � �..
.�i � tti U O. d O C � 5 � . /
X b �a q .Y� R� � v pE, R't�fi �. Ci . .
� � � 'U �i � � o � ? A U Y U:75 `p. 5 �`�q � � � - Y U �. .
M � � � �j �� �' C y .� �d � @ � y � n � � N
� p� C� �j � �.� 4] � .� �(V
�.tJJ - c Q � J t]_y 4 ' -R�&�,1.C v� O Cy th c�,y � �
-''Z � y C �q� a`�;a � fi � � C �. a y
� O : _O � �N �3z a .0 O �Z� ��C � N � � � �j b C y , �
� O �
� � ;� � ��,. �ap � m � m,g v � a � °i�' � a �
`' � �» c�� o m �',.en d' y �' � � � •.� � .
� �' J �f� y G –• eF J N '�O �
� p � u� �U � � N p � t , � C .
ao �, � � � Q.� �. � � � � �;a , �, a a
' r 3 �pc�� � � U���C . �� � E � £� - `.r, .� «� , . °i � -'
-- � 4 � a m o vi m m o �•m �� o � c c�i -c ,.;° �7 O O �
�'� ' �
:,,�
�.�
�w
�¢
� oZ _ . i
. z�
ti
.• 111 � � ' . t. i
0 v � �
'�` � � _ �
W v � .
�
. G .
•„
1 �
' � J Y. 1 � W . . , � '
. � ¢ � y ~ r � ~ •
O �' �� o. • � S z f Jj j .
� m C ` y,. � /' .,,�
-�; �, � �" .'� W �' U , .
' � � u' Z j �. N' � ��:,.. " :
, .��. � o �: F- � �. ¢ `',. "'� i
� X Z �
W z O' ?,' O" ,, I
' . F+ :� '�..`"' LL f1: �; ll Z
— �,
. . , !; �, �, %�
� � �`, � � I
',/• ,F ' - �: •
1 y `
r� x
. . •v � �' a • w -
� . �Y � • • e
� ' �,..,a I� • f/ .i p.
' �. � !a.,• i
i :.' � , rl � { �+ i " .
... .... � .' � � I',