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HomeMy WebLinkAbout1827A (11) WORKERS'COMP�:NSATIONDtiCLARAT[ON �6A663 � APPLICATION FOR ELECTRICAL PERMIT CE806G 12-801 � 1 hereby affirm that [ have a certificate oi consent to setf CQUNTY OF LOS ANGELES ` "' BUILOIN('i AN�$AFETY insure,or a certificate of Workers'Compensation Insurance,or a certified copy ihereot(Sec.3800,Lab.G} ;'�. �OR APPLICANT TO FILL IN Jpg ^� � PolicyNo. C:ompany EACH NO. FEE A�DRESS � p� Cw y� New Residential B�dgs. �j,,qq�4�r,, � Cer[ified copy is hereby furnished. i&2-Family,Sq;FtI��J�.�.-�.i�—� $ — $ �(I LOCALiTv � r �, r � Certified co Y g� P Multi-family$q,f.t. ' NEAREST py is fited with the count buildin ms ection CROSS ST department. Residential Swimming Pools OWNEa OR t,� = {� �1 FIRMNAME �W t7W�Z,a7'—� Date Applicant , Outlets:Rec.SLLi�htSiL_Sw,y� —( 0�qpoRESS o"� � S(� /`� First 20 CERTFF[CAFE OF EXEMPTION FR061 WORKERS' Total No.� Additional CITY �A� Te!No. COMPENSATION iNSURANCE ' PLAN CHECK } APP L ICAN T a (T7�is section need not be completed it the work involved � 3 O O by the permit is for one hunclred doltazs ($100)ox IessJ Lighting Fixtu♦res � First 20 pppR�� U Total No. t�� � Additiana� � I certify that in[he performance of the work for which this Fixed Applianees Not Over i HP CITY Tel No. 0 permit is issued,I ahalt nut employ any petson in any manner - PERMtT � so as to become subject to t�e W r rs'Compensation Lxws. Range_Heater�D.W. � APPLICANT �M�� ' {Vy� Oven _pryer��W.M._ ADORESS 1 y Date�3�Applican � ' i ToP _FAU '�W.H._ s v� F�" 2 i Hood_Fan .,�Other_ ciTY � y 7el No. � 1 NOTICE TO AYPLICANT: lt,after makin thic Certificate of LICENSE OR / �y ! g Disp. .�,Room Air Cond,_ t] � � Exemptiun, you should 6ecome su6ject to the Wurkers' _. PEG.NUMBER- �1-f0� Ctass d � Compensation provisionx of the La6ot Code,you must forth- POwer Apparatus&large ApplienCBs DfSTRICT NO. PROCESSEO BV •i with cumply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA { deemed revoked. (o ���,�f � UP to 1 Incl. �J FINAL LICENSEDCOMTRACTORSDECLARATIUN ����to101nc1. OA7E l a� �3 VALIDATfON Over:10 to 50 Incl. / t hereby aff'um that I am Iicens�d unJer provisions of Chapter Over.50 to 700 Inc. PiNAL � BY 9(commencing with Sectiun 7000)nf Division 3 of[he Busi- Over.100 ness and Professiona Code,and my license is in full force and � effect. Services � Licenae Number �� ��Lia C7ass- ���� 0�200 Amp.Under 600 V �.�,�� � � 201-7000 Amp.Under 600 V Contractor�L��"`V Dete lZ O�er 1000 Amp.or Ovx 600 Y� HOME OWNER-BUILDF.R DECLARATION TemR•Power Pole&Appurtenances I hereby afCvm that I am ezempt from the Contractor'.v Sign with One Branch Circuit �1B27A License[,aw for the following reason (Section 'l031.5, Busi- Additionai Sign Breneh Circuits �� � � � �� ness and Prufessiuns Code): Misc.Conduits&Conductors 1 • 1 9 7.3 8 � 1, as owner.of the property,will do [he work and the Other(See Complete Fee Schedulel— structure is no[ intended or offered for sale (Section ••� 1 9 7.3 8� 7044,Susiness and Professions Code). CONSTRUCTION LENll1NG AQF.NCY Q 3,� 2—8 2 I hereAy affirm that there is a cunstruction iending agency for ihe performance uf ihe work for which this permit is pERMIT FEE 1Sub•Total) �� � issued(Sec.3097,Civ.CJ. Lender's Name PLAN CHECKING FEE (One-fourth Dermit Fee) Lender's Address PERMIT ISSUING FEE 1 cettify that [have read this appiicdtion and state that the TOTAL FEE f�? .3 above information is correct.[agree to comply with aU County ordinances and ate laws. regulating Electrical wiring, and hereby ori� re esentatives of this County to enter upnn . he a ve- ent med roperty for inspection purposes. SEE�REVERSE FOR EXPLANATORY LqNGUAGE � � Signature of Permittee Dat ( �: . � �. _� :. .�:c ^� �=,`, _ y `y _ •��:�<,'y...^J � .;' � . �� � �., i C y_ ,\y`^" q '� - - F-' � _ _ _ i ` � .`, . ��`C �' C_ _ ... �C4 .. - � _ _ � o �i .�y_:`��:.� c^= � � � `, � '. ' M c: - p.., ��� ; "n� c .: -. `- 1 ' �,� V$ . l� `, .`�, C �' _ �• r y 0`` - .._,l.. :. c - �7- '_ �� �"1 �� tJ .�..' � ' II+. , "..'1 C. V . , /y� � ` t. .' C,y.^.� 4:'1 Y C. C) _ - � 'C' `� � .^. _ � j C.'• ' C - �_ ' '.. � I � .. �' "tl ��-+ ` �. „", . L�I✓ ' � ,1 1 � � �^ �v :.. v ` C C_ _ �, ' . 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