HomeMy WebLinkAbout1819A WORKERS'COMPENSATION DECIARATION 7on6a3 ioie� �pp�eC�T10M ��R El.ECTRICAl. PERMiT �
1 hereby af{irm Ihal I have a certificate of consen��o self CE-806G
insure,or a certifiwte o#Workers'Compensotion Insurance, k�O( COUNTY OF LOS ANGElES BUILDING AND SAFETY
�r a^cerfif"��y�t r f 5 c 600,lob.C.) 'A`� / �
li y� � ompony�PS�i-�,IC.f!� FOR APPIfCANT TO Hll iN � D�RE55 (O J�J• �C.X�� �� (�G
Certified copy is hereby furnished. New Residential Bfdgs.ByP�q�,t��y ��H NO. FEE
1 8 2-Famil 5 Ft.l��_ f — s ' �OCALITY
Certified copy is filed with ihe county 6uilding inspec- Y• 9�
tion departmen�. � Multi-fomily Sq.F�. — NEAREST
g�-8� �'�-�-� E��'y/� Residential Swimming Pools OWNER OR �
Date pplican� �l,� Q��-�/u tp
FIRM NAME �y��
CERTIFICATE OF EXEMVTION FROM WORKERS' Outlets:Rec_Lighi_Sw._^ oDRE55 �O �•�f/� � � W
COMPENSAiION INSURANCE �
(Tt�is socfion nr�d not lw complafod if tho work involved by - Firs�20 CITY ��j,_ Tel.N . ��{ t
fho parmi�h for ona hundred dolbrs(i100)w lesc.) Total No. Addit�onal Y L 1 Q �� /`7�t
I certify ihat in ihe performan�e of rhe work fvr which ihis PPIMCANTx
permil is issued,I shall not employ any person in any manner � L
so as lo become subject io the Workers'Compensation laws. Ligh�ing fiztures First 20 ✓ ADDRE55
Additional
- Total No. CITY Tel.No.
Date App���a�� Fixed Appiiances Not Over 1 HP PERMIT ,,y,,�
NOT{CE TO APPUCANT: If, after making this Certifimte of APPUCAN7 � �'e(r�l 1" ��j
Exemption, you should become subject 10 the Workers' �Range_Heater_D.W._
Compensa�ion provisions of the Labor Code,you must forth- Oven _Dryer —W.M._ ADDRESS ��� �
with comply with sucR piovisions or ihis permit sholl be Top _FAU —W.H.—
deemed revoked. Hood _Fan _Other� qTY 'v,er � Tel.N g� �
LICENSED CONiRACTORS DEC�ARATION UCENSE OR p�7 /�
I hereby affirm iha�I om ficensed�nder provisions of Chapler 9 Oisp. _Room Air Cond. --- REG.NUMBER QL_ L ��0� `� � �
(commencinq with Sedion 7000)of�ivision 3 of the 6usiness DISTRICT NO. PR ESSED BY �
and Professions Code,and my license is in f�ll torce and effec�. PO"'e�Apparotus 8 Large Appiiances _ �
�+ f'� )(� Size 8 Type HP,KW,KVA,or KVAR � t
Litensa Number �t""�� Lic.Class�= V
Up to 1 Incl. FINAC
�1'�p �,�• 8�.JC�-8.3 Over I to 10 Incl. DATE � SQ — VALIDATION �
ControctorG I �� Da�e Over 10 to SQ Incl. �
FINAl ~
❑ I am exempl under Sec. Over 50 l0 100 Inc. BY � �
8.8P.C.for this reason Over 100 � �
. Date: Services,Sw6d.,MCC 8 Panel600rds � �
D-200 Amp.Under 6�V
Signature 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp,or Over 600 4
Exemption for Reg.Maint Eled �
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �
� HOME OWNER-BUILDER DECLARATION -- . � 4.(''�
Sign with One&anch Circuit
. 1 hereby affirm thot 1 am exempt irom�he Controctor's License A����orwl Sign&anch Circu�fs - a + • •i
law for the following reason(Section 7031.5.Business and � --
:� Professions Code�: , ' �
� Misc.Cond�its 8 Conduciors i ,; .' z
� ❑ I,os owner of the property,will do the work ond the ����
strucrure is not intended or offered for sale(Sedion Other(See Complete Fee Schedule)_ � � : _ �, �;-�_ �
( T044,Business qnd Profassions Code). R. � 'y��
� CONSTRUCT40N LENOING AGENCY �'"��(- �-�%<'
� I.hereby affirm thot there is a constmction lending ogency for �
1he performance of the work for which�his permit is issued pERM1T PEE (Sub-Tofa�) � -
(Sec.3097,Civ.C.).
� PIAN CHECKING FEE .
Lender's Name /Q
PERMIT ISSUING FEE /
Lender's Address
I certify�hat i have read this application and stote thal ihe TOTAL FEE � '�
above information is corred.I agree to comply with all County �
ordinnnces and Smte laws regulating Eledrical wiring,and .
� hereby au�horize representatives of lhis County to enter upon . .
the 6ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
l�l1il'1�� y��.L,.�, 8-25--83
Signot�re of Permittee � Date �
�
C
-� "
D Z�
-p V 'L � � C C t -
. -o c ° a`^ m� o D
d� do° o.c '` Ui�.° �.�n �m �
'y`m� p S1 � G 7 � y � � d E C
. J' `n.L±� O Tn O Cf 0. t�� .5.� W d o F^ @ S E�. v >0 v�
C' > C 7i V
.00T�O�OCOC�N ON � ;� O ; ooN .
"i3 t0�N 9t O O�i C '6 w"$� G O'0'' D O
Jo o �� oo£coD�T ' m poD � sT� _ . .
� �- � 01 Q i1.�n O $ .3 N � � D U • C � i1'
y L�o �o„�,: `-- � °'. > �o �-o°��m „= °m.ur u o
O cu� � ` �°, o'� c �,� ag� os.00t► " `��' a
�'eL oo �„ -� m ,c Q, o o p � „ yo m
ts! »- o c z °�E c o E . ° c' D"'a'd o m.� a7+ �i m .d� N �,
Q a o 6, o `a�u �% ° o o s�c m�v=o o s a ? y \ .
:y � ���Q�� C m�y� � � „ o a> � �,•� a
� x • o vaa -api o= E o ° �'� Eo m � � E 4. o ` n�
4� � � V� C m 4 C"a y L �:�� C C C D O 6 O G'p p p v q 2.
� � ° 0 8`.n~ � „'t�o o�?' .:Q"�w N � o ���v v y o O
7 '" mN ��ov�or� >ome`° c.= �� >i?:� � as C>
m ps m .„u N�,,,,o n p u ,o„ 6 5�� o.tv o ��` o m
� s w��..rQ',s �o m o ov�.,.:��;,9 � � a,3 0 .,.
Z � b C' O-�'-X�''4 � � ��in V N L � c E' a �-
'?� s,c o° O p u�us.W? �'i O ,°nO �i �'
a 4 J N N,Q�•s e e � i„`c�o s....
o 'o
9o � c� ��uu�N�n �
�, � ' QE
s ° m °
�
, \
� ,\ `�
�
, \ y •.
w A� \
Y • ` \ \ \
� \
� � \ '`\ \
N Q �\ � � � � '� �
C� � � ,, � �
C \ e `
O l
r ti �
P � � `
` W \
� � � ��� �
r
�+ oc � I �' `
7 r 0
Q � 3 Z' �a. � �
� °` � ° W a � 4 �
a �r�L�, � � � �''O 7 2 0
r �.
� Z � 3 � a .
y ':�
Y
� . .,.�"'�,
' �. ' .. . ' , \ `
` , ///_"-.'�
�t .� . !/'�,.�`�
~ ` � � ./�,��"�./'
��