HomeMy WebLinkAbout1607A (17) i WOHKERS'COMPEN5AT70NDECLARATIDN 76A663 APPCtCATION FOR ELECTRI�AL PERIV1fT . �
CE$O6G(2$01
[ hereny aferm that I have a certificate of consent m se�f COUNTY Of LOS ANGELES BUILDING ANO SAFETY
, insure,or a certificate of Workers'GompensaHon Insurance,or
�. e certified copy thereoP(Sec.3800,Lab.C.)
� Z/n� � FOR APPLICANT TO FII.L IN Jp8
j PoHty Nu.5-'i'.=-'] ComPanY�t$te �i-i"7. '_'L.IIr AODHESS 21�;) �.:OCi:V ?'�C'C•7 :+�
New Aesidentiai Bidgs.&Pools EACH i�lo. FEE •
� � Certified copy is herebY furnished. 1&2•Family,Sq.Ft. $ "' a LOCALITY �_gPCR� 4�1T
EAREST
� p y ginspection Multi-familySq.Ft. � CROSSST F.id�e 1,2ri? .T'.,'�.
Q Certified co y is filed with the count buildin Residential Swimmi Pools � �
� departmenL s. � PIRM NAME ohn O�ZSb
I ;,r,�.,� Aleha E'-oas `�v: _ � .;
� Uate ��-� •' Applicant��4 �/ Outlets:Rec._Light�Sw.� ADDRE55 i,°i�F31 �At,' iiVO.� � �
i Firs[20
CbRT1FICA7E OF EXEMPTION FROM WORKERS' �„r, ( O_�
� TDta�No. Additional CITYi_�,;,t�]pX'1?n Tel No.77� .,�.j'22
COMPENSATION INSURANCE �
PLAN CHECK LL
APP�,ICANT s?rF1d t'`30ti e O
(This eecHon need not be completed if the work involved U
� by the pexmit is fm one hundmd dollars (SI00)m lasJ Li9hting fixtures First 20 qooRES57]nl��,r„ _TZIlC15cjUltO
Additional a
Tatai No. �'.r�Il� �� ��� 7ei No.�. � �
1t I certity that in the yertormance of the work for which fhis fixed Appliances Not Over 1 HP - CITYW• + �--- 52-1�7�
� permit is issued,7 shafl not emptoy any parson in any manner ,— PERMIT , V
so as tv 6ecome subjeCt to the Workers'Compensation Laws. flange�Heeter�.W. APPLICANT =+7^�'+^ ����^ a
Oven _Dryer_W.M._ AOORESS�.�Q�� � �
_ E. .�rz.nc';qt�.te z
� Date Applicant Top _FAU _W.H.._ �
Hood_Fan —Other_ C17v i1, C�vir.a Te1No.:(Z-�.]7S
NOTICE TO APPLICANT:[f,after making this CeHiffcate of DiSp. �Room Air COod.� UCENSE OR 2�pn/„] y-53
{ Exemption, you should become subject to the Workers' REG.NUMBER Cles:
� Compensatlon provisions ot the Labor Code,yon must forth- power Apparatus&Large Appliances DIS7RICT NO. PROCES D BV �
with comply with such pruvisions or thia permit shatl be
f Size&Type HP,KW,KVA,or KVA ./O �, _ _ /
deemed revoked�. �u�N
? Up to 1 Incl. � �1
? FINAL
i Over 1 to 101nc1. OATE � J� �5-�+3 VALIDATION
LICENSED CONTRACTORS DECLARATiON �
Over 10 ta 50 Inel.
i I hereby affirm that[am licensM under provisions of Chap[er Over 50 to 1D0 Inc. 8Y a�
9 (commencing with Section 7000)ot Division 3 of the Busi- Over 100 �
� ness and ProTessions Code,and my Iicense is in full force and � ��'�
t effect. Services
� '+rnn57 �-*_q�. 0-200Amp.Under600V
� License Number «���"�� Lic.Ctass � �
t;l c•1'�1 O � 201-1 D00 Amp.Under 600 V
� Contracto � �te �����2 Over 7000 Amp.or Over600 V '
HOME bWNER-B ILDER DECLARATIDN Temp,Power Pole&Appurtenances
[ hereby effirm that I am ezempt from the Contractor's Sign with One Brdnch Circuit �1 6 Q 7 A
License Law for the following reeson (Section 703I.5, Busi- Additional Sign Branch Ci�euits
ness and Professions Code): . µ�`. ...��2
Miac.Conduits&Conductors
� 1, as owner of the D�operty,will do the work and the Other(See Complete Fee Sehedule�— � � • s 3 8.5 0
structure is not intended or uffered for sale (Section
9044,Business snd Professions Code). . • a •v��O`
� CONSTRUCTION LENDING A(TENCY . . �
t hereby affirm that there is a construction lending ugency �•z� q-8 2
for the performance of the work for which this permit ia pERMIT FEE (Sub-TotaU Q
� issued(Sec.3097,Civ.CJ. 30
� Lender's Name PLAN CHECKING FEE (One•Pourth Permit Fee)
� Lender's Address pERM1T ISSUING FEE
� I certify that I have read Ihis application and state that the TOTA4 FEE (�
above information is correct.I agee to comply with ali CountY
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of tfiis County[o enter upon
� the above-mentioned Propetty for inspection parposes. SEE"REVERSE FOR EXPLANA'CORY LANGUAGE
� 82-
i natq e of Permittee � Da e '
� /
... 5
. ,
`l '-�
1 � F
1 ' i 1 " , . , � , . . � . "
' .. � . ' . 1 . .
4� '' 1 ' i ''. , • .., '
- I 1{ �1 � � '..� . � � m
�
. 1 ' , { , j " •� � 'ft C � � L U Z � ..
� f . � l ; , � Q 'z f' � -� � Cj � '� DL`
j ' i , �� %1 i �I: t m � � � � � 2 9 O � .
I �n c> r
� i �`i � � � 11 i ' :' '{' . - ,1 O C cmi � �i Z ym t�i � .
i . 1�� , . .. ,� ' . . � += � t --� i i p � � D
� `i � � Z 't z �o r
� , I! � �s � . � � '=i � p m
i l � � T � ' x m
m '
, 'I. . ,, � 'j �.,f ';� i o � ; , ;
I I � 1 c� � ', '�._.
: � I , �::; ` ,, � � ---.� -
i i I ; � � 1 0
� F ` ` t �� 'i
� I ` 1� k 'i . : � ' �
i '� .t � ; � , � i I ' �� 'I 4 � �� m '
I '�l ' 1 �E !� `i ,� I
i � '� �i M �
` I . i . I .. � � NZ
4 � ` '� �� � �m `.
1
` �-t�-t
1 ' � i � ��I
�,` � } � ' I mN
, 1 ,,
� � I
`
i
�
�
�l
� ' t
'1 �
� � i . , '.
� a�.r
� � � w�S' w�n"�° ?'» �.?
� 1 f c� O<SO .�.., �.�� �o p 3.3 ,��, �
p 'C <V:'J � O' t �O N
�.�.,O �m e�i O n n v, 7� ^,�,�p � O C.� S A � � d 0
� , . . � A.3 S '� � ,^y O� .. 0 O � t° y r" � .O c:y y �.
� OO�� O �� N'OR'�Q'»O � n ^ eo .R�°., i �•A� ► [ri
�y a `° � . ,� t s��.c N a."'�--'_ �-.��,_ < <; 0 3 '�d
O � F' 3 �
o � 4 �.3,
� � �'' „C ro �� � o a �o� oc�:�'� o Ri�.s o .,� � �o a," ,-°�^_� C
. ' ,� A n ro�} �� �'C C� �.� 3 � � M p = � H r�O S'CS j � �+ R r Cr'
� . M �7 'S �0 r�.!C .� � J Q V� R .3 ��Y � C O G1 v
' - O `O '�'p O,� O�•,R'c in 7 +s�«' O�.O � � ..,y � �
. � -� n n � 2 �. p � Q rp ,^..,cn;� w�n N �,t� �� y � � �
, � a 3 0'$ � a� o,f9 c a `, � " � � g $k,x �
, m P- Q'� Rs� � ya'G"� n � �` C ti� " ",,^ n m�'-` " lT1
, i '� c �•G•aco � o n'ry ^'p ��oy �� � �;°- v n
� `., o= � � � -� �.'
� � � � N � c�'o a �.e " O "' �.`� �Y��� � `�' �� � _� � �
i. . •"•+ � T � c �T c =fD ¢ ,�,�,_fl a�e � `,o.,v�, 4 s C.�.`t.� �
' . p,E �o eseC h G.�.. `e�0.�'C7�0 �b � � fn.^J �}
. ' C' .�.�"t0 = O�G n'v p' � p �p � y,p T. Pt p R•�e�j � 0
� �...R n .y
- � S'S'�•3'_ ^6•, C n 'J 3 .�.. f0 'T .� T. ...s vi � 0 � f
3 c 3~' n t�o ",7 O'--n� � 3 � •.. -e O S �
" . ` '° O S� � _ <° y s ^.`^ w,��.�- 0 y �ea n p a�
� � ro A � Q F 0 'i O C b � k�?9�n p � `,w...pi
' 'e �-'c � F �o ,,, ee m .n < .
�� 'd `° p a � A� �.` s � �o Y :"v�
� � . .i � Q�. '0 0.' D 7 G �.�� ie �C r" a -
_ s A D �^ R`D.� G 3—�+�....�
� . . �O �`� l.�--�'r'
� � ��.�.�-�'�"��....,� �
'_-__
�i"
�. �..���/�"'� _---•