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HomeMy WebLinkAbout1817AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, a�o cerci � th reof Se . 00, Lab. C.) r -V om G?J��t-Anca Certified copy is hereby furnished. (21 Certified copy is filed with the county building inspec- tion department. Dare Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section naafi not be cornplefed if the work l"olved by the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the tabor Code, you must forth- with comply with such provisions or this permit sholl be deemed revoked. LICENSED CONTRACTORS DECLARATION. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number '"1't `. 2A 2— Lic. Class GH Q Contractor y I RIP ' Date ❑ f am exempt under Sec. B.&P.C. for this reason Date: Signature Exemption for Reg. Maint. Elect. SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reoson (Section 7031.5, Business and Professions Code): ❑ 1, as owner of the property, will do the work and the structure is not intended or offered for safe (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon th?ove-mentioned property for inspection purposes. Signature of Permittee L Date 5A663 10/8) APPLICATION FOR ELECTRICAL PERMIT R$—,%COUNTYOF LOS ANGELES BUJOBILDING ANDSAFETY j� L� FOR APPLICANT TO HLA 7 �� ADDRESS ORS 5, K.DI r lY)Q, 1/1 V16 EACH t80. C New Residential Bldgs. .18�fpgj;,� FEE � qj 1 & 2 -Family, Sq. FE !� — — S LOCALITY W Q I VIU-1— Multi-family Sq. Ft. NEAREST CROSS ST. Residential Swimming Pools OWNER OR ,- 4J 1 Outlets: Rec•___,�ight Sw FIRM NAME ADDRESS h�0 1r 41" `1St-, 100 First 200 Total No. Additional n` CITY -CY'R/2 Tel. N 7 PLAN CHECK x Fixtures 20 ,APPLICANT ✓ Lighting First ADDRESS Total No. Additional / CITY Tel. No. Fixed Appliances Not Over 1 HP PERMIT Range_ Heater_ D.W. — APPLICANT Oven —Dryer _ W.M. — ADDRESS S C Top _ FAU — W.H. — CITY r N Hood _Fan _Other_ Disp. _Room Air Cond. LICENSE OR �?T/eII �'7?Tel. REG. NUMBER I 242— Class.G—iD Power Apparatus & Large Appliances DISTRICT NO.PR D BY >_ Size & Type HP, KW. KVA, or KVAR a O Up to 1 Incl. FINAL V Over 1 to 10 Incl. DATE r G VALIDATION O p Over 10 to 50 Incl. FINAL ~ V Over 50 to 100 Inc. BY LU Over 100 Services, Swbd., MCC & Ponelboards Z 0 • 200 Amp. Under 600 V 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V Temp. Power Pole & Appurtenances Sign with One Branch Circuit Additional Sign Branch Circuits Misc. Conduits & Conductors. Other (See Complete Fee Schedule)_ UY.� PERMIT FEE (Sub -Total) PLAN CHECKING FEE PERMIT ISSUING FEE �Q TOTAL FEE 4 '6' SEE REVERSE FOR EXPLANATORY LANGUAGE ■ § § ƒ}\az o Ix }}/}mom/a|§ G[§o\;g. a$\ k=`§%°-f.~� ;..%,2�_� z 9 .®°±«%>|.�;-- �a`e02(E Cc 3§a��,�E\& Caƒ�»` {\, �m) &k o®j,eoE$_}.| \u^ f©wuE:�ECL cmƒ 7 � ,E2 r o2` Co .. { f -V2�>t/ &.rƒ$\e % w|Ek (J �{UJ 2% \|$% ƒ2a )ƒ`N _ � 5 2;�£-moo£![-» e7�@22�1>} /- § - oe�k■®�, §_ a3=£3 %f§-o,o » tn G U §©7«|�0 °2§{�-¥%£2«2{ir §; := $ J >,—CL _ C £l7�;EI�fƒ2Euc�l�«„%�_«� \ } ` %$ftp$|±�|$3:f rt-cu«'Wol Ej j�`'n /\))k§i }/}\\{{O,C, } } ■ § § � k � f . � � ! U J Izz ( ƒ } k } \ ° \ [ j 2 \ ƒ \