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HomeMy WebLinkAbout1714A � WORKLI{S'COMPFiNSA'PIUNll�CLARATION 76Afi63 t ''�. APPLICATION FOR ELE�CTRICAL PE�RMIT CE�806G(2�li0) � �� � h�reby affirm that I have a certificnte of consent to seli � CO�NTY OF LOS ANGELES , BUILDING AND SAFETY insure,or a certificate of Workers'Compensation insurance,or , a certitied cnpy iher of Sec.3800,Lab.C.) �,ciob�l��6 �1�.U7(1 ',BSOC, FORAPPLICANTTOFILLIN ��a 2�0�. Sunbri�ht .�ti. � Policy No. Company EACH NO. FEE /a�DRESS ❑ New Residential Bldgs.&Pools — Certified copy is hereby 1'urnished. 7&2-Family,Sq.Ft. $ — � LOCALITY Di amond B�:T' Multi-famflY$q.Ft. — EAREST Certified eopy is fileJ with th nunt b ildinq in ection CROSS ST �dep�rtment. � Residential Swimming Pools OWNER OR �f FIRMNAME��u1 Bordwell Datz�Ba�pplican[ /` � .Outlets:Rec.�Light_Sw.,_. MAIL � Fifst20 AD�RESS s�'mL' _ t� !� � CIRTIFICATR QF�Ii.XEMPTION PRUM WORKb:Rti Total No. _ Additional CITv Dl�:. �i�=1' Tel N 7 �b 7 COMPiCNSATIUN[NSIJRANC� PLAN CHECK � APPLICANT �p (This section need no[ be completed if tl�e work involved Lighting Fixtures First 20 AooRESS � by the pe:mit is for one hundred dollaxs (5t00)�or less.) qdditional - Total No. � I certity that in the performance of the wnrk for which this �� CITY Tel No. C�) Fixed Appliances Not Over 1 HP ...— � permit is issued,I shali nut employ;my person in any m:�nner . PERMIT Thomc��:S ixY'Otlti � U So ec tn AecOme subject to the WUrkers'CUmpensation Laws. Range_Heater D.W._ qPPLICANT � � � Oven _Dryer_W.M._ ADDRESS 1.2900 GG $lvd. ; � , ` Uate Applicant . " Top ____FAU _W.H._ ---�� . '�— Hoad`Fan _Other_ GITY CC ._�e�,No�—l� ` � �" NUTICE TO.41'PLICANT:If,flfter making lhis Certificate of � Disp. _Room AirCond._ � UCENSE OR� �F ' ' �- i;., �Ezemption, you should Necume subject tn [he Workers' REG.NUMBER Z Cias�"(i j S� Compensation provisions of the Labur Code,you mu5t furth� power Apparatus&Large Appliances DISTRICT NO. PROCESSED eY P with comply with sucli provisions or this permit shull be '` Size&T e HP,KW,KVA,or KVAR 5 � deemcd revoked. f� � , }y Up to 1 Incl. FINAL �� r g Over 7 to 101nc1. pare VALIDATION k, iicFxsr:n coNTRnc•roas n�cLwxw��ioN o�er i o to 5o i��i. �"' 3 i_ �� f hereby affirm thxt I nm licensed un<ler provisions nf'Chap[cr Over 54 to 700 Inc. FINAL ^ ( � BV ; 9 (cummencing with Section 7000)of Uivisiun 3 of the Busi- .Ovcr 100 ' �� ness and Yrofessions Cnde,and my license is in fu11 force and ' � � effect. lServiCes � Lic�nse Number��Lic.Ciass�`o.�� y �0-200 Amp.Under.600 V �� p • 201-1000 Amp.Under 600 V.� x �F�� Contractor Tnom�s �'a'2'O't�e_3�I.�U2 : Over1000Amp.orOver600V �: � HOMli OWNHR-HUII,llER DECLARATIUN �7emp,Power Pole&Appurtenances *}g [ hereby affirm [hat 1 am exempt from the Contractor's 'Sign with One Branch Circuit Y Additional Sign Branch Circuits a 1 `�1 Q A, f License I.sw for the followinq reason(Section 7031.5. Busi- k � ness and Professiuns Code): �. Misc.Conduits&Conductors �#° °'° ' �� 4 � � 1, as owner of the property,wili do the work and the �pther(See Complete Fee Schedulel— '� n s 1 ? 4� ; struc[ure is not in[ended ur offered for sale (Sectipn p 7044;Businesv nnd Profeseions Code). - � coNsrizircrion LENoiNc aci::Ncv — �;� a 1 2 1 0 a �3 I hereby affirm that ihere ia x constructioi� lending ngency ;' �� for [he performance of the wurk for which ffiis permit is pERMIT FEE (Sub-TOtal) n 3'��`g 2 � issucd(Sec 3099,Civ.C.). 4 ; Lender's Name � PLAN CHECKfNG FEE IOne-Fourth Permit Fee) i, �r+'111f::T1C� ;:If18T'].Ci:: � i: Lcnder'�Address pERMIT ISSUING FEE r, r. � I certify that I have reud..this 9pp�icetion ssnd state that the TOTAL FEE /� i; � ahi�vc inPurmation is correct.I agrce to cnmply with all Cowi[y � ;�ordinances and Statz laws reKu]ating ElecCrical wiring, and �� ti herehy thorire represen[ativ e uf this County[o enter upon � � ;, �!the ah ve .ent � d property o�inspaction pur ses. 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