HomeMy WebLinkAbout1654A y WORKERS'COMPENSATION.,DECL.ARAT.I.9N.. � ��3 �o�B1 � qpp�fCATION FOR ELECTRICAL PERMIT �
r I here6y affirm that I hava a certificate of consent to:elf �-� � �
�nsure,or a cenificote of Workers'Compensation Insuranca, COUNTY OF LOS ANGELES BUILDING AND S
or a certified to y ihereof Sec.3800,Lab.C.) � ,�jj �`�
� -^�G�2-�f-�5� i
P❑ollcy Nd. Compan�� ��. FOR AVPLICANt 10 Rll IH ��B
EACH NO. FEf A����
� CertiSied copy is hereby fur�ished. New Residential 81dge.8 Is. —
OFI 1 8 2-Famil 5 Ft. s — 5 - LOCAUTY
���L Certified copy is filed with the county building inspec- y 9' NEAREST
tion deportment. M�Iti-family Sq.ft. � CRO55 57.
Date ��p qpplicont� ,�' Residential Swimming Paols FOR NAME
CERTIFICATE OF EXEMPTION FROM WORKERS'. OWlets:Rec�liqht_Sw._
IL
COMPENSATIONlNSURANCE aooaess ! SV/U
Firsf 20
(This t�ction n�ad nof bo compl�Nd f!1h�work invelv�d by 7ota)No. � Addilional CITY 1 Tel.No.
Rho parenit is for oM aundrvd daUan(S10Q}or laas.)-
PIAN CHE
I certify that in the parformance of the work for which�his APPLICANS
parmit is issued,I sholi no�employ any person in any monner
so as to become subjecr fo the Workers'Compenso�ion Laws. ��9hting Fixtures Fint 20 ADDRE55
Addilionol
Tofal No. CITY Tel.No.
Date /+rplicant fixed Applinnces Not Over 1 HP PERMR
j TICE TO APPLICANL If, after making this Certifitate of ,qpp��q�_ _ � '
F .nptioa, you should bemme�wbjed to tbe Wwkers' Ronge_Healer_D.W. _
�ompensation provisians ot the tabor Eode,you musi forrh- Oven _�ryer _W.M.— AD�RESS
with tompfy with such proviyions or this permif sholl ba Top _fAU —W.H.— • �
deemed revoked. - Hood _Fon _Ofher_ CITY , �� �� Tel.No.
L4CENSED CONTRACTORS DECLARATION uCEivSE Oa
I here6y a4firm that 1 am licensed under provisions of Chap�er 4 Disp. .—Room Air Cond. — REG.hlUMieER � G9ss� ..'
(commencirg with Sgttion 7000)of Division 3 of Ihe Business pOwer Apparatua 8 Lorge Appliances DISTRICT� PROCE � 0.
ond Professians Code,and my license is in iull force and eff�ct.
'^• ,�] Size 8 Type HP,KW.FNA,or KVAR u
License Number-C�—Lic.C{ass `�- " FINAI
f/� Up to 1 Inc1-
C�L'�C ���0� Over 1 to 101nd. DATE � �d_ ��t' VALIDATIOH Q
CoNractor��3Y� Dote Over 10 to 5�Ind. 7 F'
❑ fINAL V
1 am exemp�under Sec. Over 50 to 100 Inc. B� d
B.&P.C.for this remon Over 100 � � �
Services,Swbd.,MCC&Panelboards
� Date: 0-ZW Amp.Under 600 V
Signature 201-1000 Amp.Under 6W�V I
❑ Over 1000 Amp.or Ove�600 V
Exemp�ion for Reg.Maint.Elect.
. ,_ i .,.,i.:,
SINGIE fAMIIY Temp.Powe�Pole&AppuAenances .
HOME OWNER-BWLDER DECLARATION Sign with One Bronch Circuit r�?�= ' ` - ".-
{ ehy affirm thot I am exempt from rhe CoMmctor's license qddirional Sign Bianch Ci�cuits � ,. I
�_.o for Ihe following reason(Section 7037.5, Business and 'j a , -�i..
Professions Code):
❑ I,os owner o4 the property,will do ihe work and the Misc Conduits R Conducrors a �'e�-.--��,�ii_�
sirvdure ia not intended or offered for sate (Sedion Othe�($ee Complete Fee Schedule)_ � .
7044,Business and Professions Code). ' _._ . —� -
CONSTRUCTION LENDING AGENCY �
I hereby affirm that thera is a construction lending aganq for u�
Ihe performance of the work for which this permit is issued pERMIT FEE (Sub-Totvl) '/
(Sec.3097,Civ.C.). �
PLAN CHECKING FEE �
lende�'s Name pERMIT ISSUING FEE 0
tender's Address (7�
I cer�ify that I hove read this applimtion and sia�e that the TOTAL FEf d-
above informarion is c«recL I agree ro comply wi�h oil Coonty I
ordinances and Stote taws regulating Electrical wiring,and i
here6y authorize representalives of this Caunty to eNer vpon
the above•mention roperty for i�spection purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE
� �_�� _ I
Signature of Permiuee �ate I
y�7��+r P�• � ,t..�� N.O�� . ..b L y O O=� .�.
•� �C� � 3 � a a ' � 6 �n � ��� •
� � �n O O�'� a� 4 N c m
6^ 'Z'd O N C [C'�v� W.c O U Q,0� O b p O _.
� C G L`�p G O V� �.t.. � m �D.�
� V � O u O�n p p C � a D p C�.c �� ['� q -r
Z � h o . � ° ° E r E ° m � � �~ m t E s £ �—
Q E �'E�•= m`�..��..°�i -°�°-o p� o �o aM
oc o a '� ._ ,' p�a � � i w =�u e o a m � °
g . ° 3 �' ° E o c b
uU,, a`� ¢ � o E � �'.c� c ro E �'� o ° a,c,c° a`@ a
p y rn�° � m o p,� o.Q a p.C in a t �.� c� �� I .
C
' � U O ' �.G ��1 � W [ � L' � �„' p� � �'O � .
�. E° N M aN a� � � �'+°o o�a` o N�°-��� � c
� °.° Co.� �� o . Q� � � cv � m ` • mo ' �
p OI�.1 N �� 3 !4. V� N
m — O U ]y� b QI � 0� � C � �
w L�+m � � o u "co o °am o � �� °�>m o_ o -°o °' .
Z Q y u� a...Fv °c c 3 E o m � .3 � c �
E,�4 m w��Q oo�>-:oti � ° o ao ' m � �
� � 3caoos '!� m ° uo " xm � " d oma o � °
�° M N�r o on-�o� a.o�°�� m= F.o E '�� u
w o»,� v o .c — � � � o.o� x Cj
m „ m � a., Qov�ut ° �� k^_+-°s'o o � � ° � �
m < < � �V C C O n v y �� [ L C-D � y C
t � " o- ur � o �•`+ e= om �.toon as ;
— m m o 'PEU°�n �,°n uv° �'�'.° 3 3 � E o °e ° m o O
�W
� (
Q
Z
7�
N
C
� �
Q ��
O
C
O
♦
w
�
�
W
j W Y N S
�
� a O � °E p ,
o W 3 Z = Z ...
Q a g O w Q O
a w (9 Z j w � Q �
WZ = � �C 3 ti Z O
5 � 3 �. � � �. z
��