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HomeMy WebLinkAbout0951A (5) _ , �,��, �� � , l':O4KERS'CO'SFENSATION DECLl�RATION �tA�� �o�e� APPLICATION FOR ELECTRICAL PERMIT ' `,F'� � 1 hr.reby ofLrm ihnt I hnvr. o tcrlifica�r. oI mnsent m self �F"n�' insure,or o r=riiFicnie of`lJor4ers'Compnnso��on Insi�mnce, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a cei�i(ied copy thnreof�nSeb?600,L}n-b.C.) � Poli�y No���•npony�/� � O � FOi AYYLIUNT i0 FILL IN JOB � Cerli(ied cepy is hereby furnished. Nr.w Resid�n�iol 61dqs.8 Pools Fa.CM 1.'O. �FE ACDPESS IV (L�O�� � S — 5 LO:ALITY J Cenified copy is filed wirh ihe couniy buildin�inspec- 1 8 2-Family,Sq.FL I A —� NEAPlST /' � tion�lrperimcnt. ['� 1.Aulii�fomily 5�.FI. C�O55 ST. (�- I � S/g�r, �P y�( /�'�y� Residenliol Swimminq Pools O'f11.ER OR Dafc_( A Iic�nl�L�r`-"� � fIA•.1NAME E �R CERTIFICATE OF ExEMPT10N FROM WORKERS' Ou�le�s:Rec_L�ght_Sw._ � ' ` ' �'�'��� n ��f COVPENSATION INSURANCE ACDRESS J ' l. f�/ D� / Thi�s�clion n�ad not bs com I�tod if the work fnvolved 6 First 20 � p Y Tc�nl No. Additional CITY ��am p�Q ��Tel.No.&'G�•.� D th�parmit fs for ono hundred dollon(SI00)or I�ss.) I cnrlil 'hnl in Ihe e�fermnncr of Ihe werk for which this P�nN�MECK Y � AP�ICANT �ermil is issue�l,I sh�ll net employ ony rr.rson in any manner so as�o F.ecnmr suhirct io itie Workers'Compensa�ion Laws. L�qh��n9 Fi�lurrs First 20 ADDRE55 To�al No. Addi�ional CITY Tr.l.No. Da'e nP{����a^� Fi.ed Appl�on<es No�Ove�1 hiP pEqy,i� NOTICE TO AFPLICANT: If, of�er mnking Ihis Cerlificare oF APM��4NT y� �EG - -- ErPmption, yo� should F.Pceme subjec� io �he Workers' Ra^9e_Hea�er D.YJ._. Comnertso�ion provis�o�s of Ihe(nbor Code,ynu mus�fonh- Ovon ,Drye. �y�r.p.1._ ACCRE55 j��Lc � E � wl�h comply ith such pro�isions or ihis permil shall 6r. Top _FAU —V�.H.� CITY _� Tel.No. deemed reveked. Hoad _Fnn _Othr.r_ �� �r� . LICEN�D CO'dTRACTORS DECLA4ATION LiCF\:E OW I hereby a!firm ihot I o�n licensed under provisions oi Chaptar 9 Disp. �Room Air Cond. _ rrEG.tvu.�nBFR� Q •� Class. � � (t�mmen;inq wiih Secr�on 7000)el D�v�sion 3 of Ihe Business paM,P�qnrnrotu5 8 lerge Applionces DISTRICT NO. PROCESSED BY O and Profess�ons Cw.'e,ond my Gcense rs in full force ond eHeci. D C � //� Sire.8 TyFe FiP,KW,KVA,or KVAR V License Number / J Lic.Class� FINAL � / Up to 1 Incl. !.�^��S � �G���/ ('L��C �/l�/�� Over 1 to 10 Incl. DATf� � ypLIDATION W Conhncror Y�JO Date p�er 10 io 50 Incl. � F"�rrnr� �- I am exempt under Sec. Over SO to 100 Inc. BY U) 6.8P.C.icr this rcason ��n��� z Servicr.s,Sw6d.,M,CC 8 Panelbonrds � ,._G G a 1 :� �n�': 0-200 Amp.Under 600 V � 519nature 701•1000 Amp.Under 600 V ,_ e e e e� ❑ Over 1000 Amp.cr Over 6pp V E.emp�ion io.Rep.Main�.EI=c�. � • • � �,�Q S�NGIE FAM1l!LY Temp.Powe�Polp 8 App�rrerances • + F�O.".+E ONJNfR�BUILDE4 DECLARATION � ° � •� ��' Siqn wiih One B•anch C�rcuii I h�re6y ef(irri Ihcl I om ezempl frem ttie Contreclor"s license ������anol$i n Branch Circuils ' ����� ��7 �aw{cr�he followin�reason(Section 7031.5, Business and 9 Profess�ons Code): ❑ I,os owner ef 1he.property,will do the work ond thr. M�sc.ConAuits 8 Conduc�ors strucrure �s not imended or offr,red(or saie(Sect�on O'her(See Complete Fee Schedule�_ � ► 7044,Business and PrefPssions Code). CONSTRUCTION LENDIhG AGENCY I hereby a((irm ihaf Ihere.is o cons�ruction I�nding agency for ��e perlormanc�ef th?wo�k for which�his permir is issued pERM.IT FCE (Sub•Totol) `a (Sac.9097.Civ.C.). PLAN CHECKING FEE \lender's Nome PERMIT ISSUING FEE Lendr.r's Address �erhfy ihat I have rend Ihis npplico�ion and s�o'e ihot the TOTAL FEE `•e iniarmoiien is correct.I ag•ee io comoly w�th nil County '�tes and S�n�c I�ws rrc�uln�ing El�clrical wiring,and •u�horir reArr,sentatives of fhis Couniy io en�er upon men onr.d properry for inspeuion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � � � \•P�e �Dn'� I ' ' ' i I I � � - .. - . ! � .. . .- � . � .. � __ �-. �. : � . � � . � � . . � � I �; , . . � _ - . .. ; i ; i . � . � _ . . - , I �;- °I . - � -.I . .. .- _ �: �- �. : . . . i � : � : ,� . , T __ __� �- _ =-_ -=-� . 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