HomeMy WebLinkAbout1714A (10) � 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. SEE"RF.VI:KSI's M'OR GXYLANATORY I,ANGUAGI4 ;�i
/�"'�'� � � ��---. t
Signature of 1'ennittee Date
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