HomeMy WebLinkAbout1775A WORKERS'COMPENSATIONDECLARATION 76a663 iOiBt qpp��CATfON FOR ELECTRfCA! PERMiT — 7�
I hereby affirm ihot I have a cenitimte ot consent io self �-� � ',,
insure,o�a cerriflwre ot Wo�kers'Compensaiion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFEi `�
or a terli4i/e�d.c��o y,,,t�h�ere�of($ec.3800,Lob.C.�
P�ol�i[y No��Compony�ND(/S�//9'L/� IOR APPLICANT TO FILL IN �OB /� ` 1
Certified copy is hereby furnished. , ��Y, New Residenfiol Bldgs.8 ols EACH NO. FEE ADpRESS�O�� �J, r/ �/
� 1 8 2-Famil Fi.� s — S IOCAIIT � � / �
Certified copy is filed with the uMy building insper Y�59�
fWD eparf enf. Multi-fomily Sq.Ft. — NEAREST n
y fyy, caass sT. ,CJ
` �� ��� Residentiol Swimming Pools OWNER OR
Date Applicant FIRM NAME N
CERTIFICATE OF EXEMPTION Fi2pM WORKERS' Outlets�Rec_LigM_Sw._ �« � L��
COMPENSATION INSURANCE First 20 ADDRE55
(Tbia soction naad nw 6�compieMd N tin work involvad by Toral No. Add�t�onal ��T �l/ � �`,Tal.No
Th�parmif ta far ww 6unMod dollars(:100)or to��.f pLAN CHECK
�certify�hat in the performance of the work for which this APPLICANi
parmil is issaed,I shalt nol employ any person in any manner
so as to become subjac�to thg Workers'Compensotion Laws. li9hfing Fixtures First 20 ADDRESS
To1a(No. Additional
Dale /+ppiicant QTV Tel.No.
� iixed Appiiances Not Over 1 HP PERMIT
VOTICE TO APPLICANT: If, oflar meking this Certifimte of / A �
� cxemptfan, yau should 6ecome su6jed to the Workers' S APPUG4NF�
Ran e_Heater_D.W.— r �
Compensation pro�isions of ihe Cabor Code,yo�must forth- Oven _Dryer _W.M._ ADDRE55 , i
wi�h comply with such provisions or this permit shail be Top _FAU �W.H.— � x /// ,/ f
deemed revoked. CITY �9i7v Tal.No,59�r(p� �
tlCENSED CONTRAf70R5 DKtARATtON Hood _Fan _O�her_
Dis �Room Air Cond. — ItCENSE OR � �+/O
I herebY affirm that I om licensed under porisions af Chapta 9 �' REG.NUM6ER Class. a
(commencing with Section 7000)of Dirision 3 of the Business DISTRICT NO. PROCESSED BY �
and Professions Code,ond my license is in full force and effect. Power Apporatus 8 Lorge Appliances �)
���jj�,��1/�)' f�� �!' Size&Type HP,KW,KVA,or KVAR ![/ Q'G U
License Num6er�y���Lic Class �� 4 tJp to i lncl. FINAt QS
������4 Date �-o ' Over 1 to 101nc1. DATE ��a��4l, YAL{DATIOH � �
0
Conlroctor Over 70 ro 50 lnd. W
❑ FINAL
I am exempt under Sec. Over 50 to 100 Irrt. BV �n � a�
B.&P.C.for rhis reason Over 10p t V� z
Service:,Swbd.,MCC 8 Panelboards �
Date: 0-200 Amp.Under 60p V ��`'� l 1�.�i N
Signoture 2p1-1000 Amp.Under 600 V TM� ` c _ , �
❑ Over 1000 Amp.or Over 600 V °`` �
Exemption for Reg.MainL Elecl. + ��`` _ ,_
SINGLE FAMILY Temp.Powe�Pole 8 App�rferwnces �
t- HOME OWNER-HUILDER DECLARATION Sign with One 6mnch Clrevit " • °�' �- -
` .hereby nHirm thaf I am exempf from the Conhocfor's Licensa qdditional Sign Bronth Circuih ^ �
Low for the following reason i5ection 7031.5, 8usiness ond ��J,C C—: G �
Professions Code): �
❑ I.as owner of the p�operty,will do the work and fhe Misc.Conduits 8 Condudors
shucturo is not intended or offered for sale(Section Other(See Complele Fee Sched�le)_ �
7044,Business and Professians Code). �
CONSTRUCTION LENDMG AGENCY �
I here6y aHirm ihot�here is o mnsiruction lendin9 ogency for
fhe performance of the work for which Ihis permit is issued PERMIT FfE (Su6-To�el)
(Sec.3097,Civ.C.�. �
PLAN CHECKING FEE �
Lender i Name ' '
PERMIi ISSUING FEE
Lender's Address
I certify tha�I hove read this applicotion ond staie ihat�he TOTAL FEE ��� j
above information is correU.I agree ro comply with all Caunty �
ordinances and S1ate Ivws regulaling Eletlricol wiring, and
her y outhorize representoiives of ihis Coun�y to enter upon
e ove-me��ioned properiy for inspecti n p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/n t'al� �/s� �
Signature of Permiitee Da�e
� �n i S 0. QI�+ in �� U"` N t � �`V O C r� � I � � . .
�b ,_�. N 4 0... 3'� ° ` a°-.v` o � m � c �._v I �
� � �' �o y "c ��-c`m'i.t o t° a"m `o_r, o� � .
� o �''�' �' Oc��o m 3 u b° ..�^ � m.c F I . �
J • � � n'« m a c h > � o,c o c-0 �� � �
O i ,� o e a o o £ � �o m' � °� m � �` � c`°' � I '
c c'� > o
'�_ � o.�a ii�� o o�' �.°� o� o m °+ ! i i
LY O O V E � O'.L. a v � �n `,� O C C � y V 0.D � .
� .._ �+ �. �.,, � m �, ' '" +� ; a V o a � � O o m � t _
L) o_ °' Q` o �� "� m s« c � ° �� � ° � a a. � ° t
� k �-� ;, o �.°.�e E� a n ��e Q�, �w 6� a � � III I i
� C a U .:.7 �u �U,e,y K 0�� a.D ` o� � ci c r, d i� I ,
- _, E— n � a3 � � " o . o�a `o h-� ��"c '_. " �; � � I '
� �%° c o � �'n a � "' q c � � « C i 7a � ' �o cn ,� i
� 61 � y '�` ~j 3 L � 4 t7 O C d Q} O Cx� 3 � L d I
u; s=+ 'w� � : cn_ a �a.w m �t �.y�„'^ o "6 `"� I
2 n .„ �..: 4� �:�y a� r. � c �.� ° ai „� 3 n � '^ �
1 � _ n � .� , �
{J v- �L �.C a+U�c n�L ?1 C~! � n C.�f 6� b�Q C' C'e ^ � � , .
'� � �C' Q b [3.e�G+�� O ��;p .4�. r. � V Qy� Q .�� w � � '
� HNw� � ai�� � a. oa�s, . =� �� E E �s a�
U -o — i� � {.�.[i� X ' !
_� o G a:�a.�w` c c V � � 4 ?��'�'�.��-a ' 4. � ¢, � ; � �
u � �,..� m a � m ° �=�'• a� �, � r c o m,si � , a C
-L J � �,c. � a o .2 p� o� .%'-en Q'c p c � 3 o v `� � c �
. .- 4) O CT E U u> rn ro. A V�U . 'tii '. � O L.'. �. � (.�. C�
� r
� � �
� ( � � f f { � ' � ,
; � � � � � ' i
_� ; I � � � � '
� � � � I � j � � � � � � ' ,
'� _ _ _T _ � I � ; i + i � � i i „ � i � �
� '� � I ; � . i � j s � ' � i
� � � ; � i i I i � E € ;
�d � �+ 1 ' � E � i
,,�. � ' ! � ; ; ! ; I � : l ''; � �
:lldE � i 3 f � I i i � i ; . � � E
E { � � � 1 � � 1 � ' � � �
i , � , , ; , f � , i ; , j �
--c�--��---;----�• —;--- . ; a ' ; � � i I � � � �
{ } (_�.. ; i � . ; , � i , , s , � ,.
; � ; ; � � ! i � ( i � I . ,;� 1
a l iJ � � i �j�� t j ' � ' � .�, }
i � � f~ ' � : �; � ` � j � � _ ` � ' � ( � � 1
, .
' ' � j `. ' . : I i� i
f� ' ` , I :
� � � ' � �� � � i � � 1 � � � � ! !
,
i._._ . __.a......_ —�_._�....�__.� G 1 � ,
; i � � ��r 1 � � � � I. � ! i
' j ; i ' � � � � { , i : ? ' ,
�, ;� � i�� 4.. ; ' i . . ; , ' i � ' .
!'% 3 �" � I ._ �1 ' na u� i ; ; � , i ' � I, ; � ! .
i %' � � � `�� >].1 '! i�� �i ' i f . , , i I i . , � i
�Q ` � cF.. ) x� � „� � !i _ j � ! I , : '4E � � . i f
� .f S q U j t I � i � 1 � f S
� �` c��cani�' '-� ��}�[i' � tY } � ; P ( ;... ' i , � i � , ,
t � � i �u ; l,,',D �r.� ) iu ��'_ '� �i• i f � ' . i ' � �
•C. � �: ."* _, Q i r .. , , , i j
1; .r. t�} � }( V r- 1' (; � � 1 � ' . � ' � i € I � �
� . __ � 1
: • '> _ 1
' ' �" � ,-3 3 A `r �u- 1,f. }� �V. I .' . � . � � . . . . .
�_._1___i__...1.--' --.s._._A�...,.__.._...__I .I : • � . . ' ' �
, � : � 4 ; � `' j � I � i � j , f
. � . i � � ( ! � � I � ; 4 , ,
. � . � ; , , j j � ; ' ; i �
•� ' � � , � � ! F i ; � 1 E ' .
. , � � ; , � ' � ' � ' � � �
; . : , � , ; � � ;
; i i ' i �� � i k j i j � � � � E � I
: � � �-�' , j� ` , ; � i � i i i � � � 1
. � , . . ; : : I � s . � �
, .