Loading...
HomeMy WebLinkAbout1609A � WORKERS'COMPFNSATION DECLARATION 76Ab63 ���a, APPLICATION FOIt ELECTRICAL PERMIT � I hereby nffirm that I have a ceriificnle o(conseN to self CF�BOGG i�s��re,or a certificote of Wo�kers'Compensatio�Insu�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or o certifie r.opy thereof(Sec.380Q Lab.C.) P❑ollcy No.p,_L[,.�t�Company �.�.�r'��� FOR APPUCANT TO FILL IN JOB • � Certi{ied co is hereb furnished. EACH NO. FEE A�DRESS PY Y New Residential Bidgs.8 Pools 1 k 2�Famil S Ft. § — $ LOCALITV �U,�, f"` ertified copy is filed with t e unly building inspeo Y• 9� _ NEAREST �"' tion department. Multi-family Sq.FL CROSS ST. r,J �fc.�� � Da1e��Applicpm ` Residentiai Swimming Pools OWNER OR le] FIRM NAME „� `K. Q ^_�7 CERTIFICATE OF EXEMPTION FROM WORKERS' nnAa Y � COMPENSATION WSURANCE Outlets:Rec_LigM_Sw._ qpoRE55� 1(j '` '� This section need not be com leted if the work involved b Firsi 20 �. � P Y Totol No. Additional ❑TY� .11�� �' Tel.No.�'� l� � the permif is for one hundred dollvrs'[;100)or less.) I cerfif ihot in fhe erformonce of the work for whi<h ihis PLAN CHECK � Y P APPLICANT ` ��L � �.> �permlt is issued,I shail not employ any person in ony mnnner .so as ro become subjecr to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS �� �` t � Total No. Additional CITY � Tel.No. Data Appliwnt Fixed Appliances Not Over 1 HP PERMIT ` NOTICE TO APPLICANT: If, after making Ihis Ceriifimte of APPtICANT'' .M � �� Enemption, you should become su6jecl fo ihe Workers' Range_Heater_D.W.— � Compensation provisions of the Labor Code,you must forth- Oven _Dryer —W.M.� ADDRES i ^ ,�?� ...vL� with comply with such provisions or this permit sholl be Top _FAU —W.H.— : � deemed revoked. Hood _Fan _Other_ CITY ��_d Tel.No.� _ � LICENSED CONTRACTORS DECLARATION LICENSE OR � I hereby affirm that I am licensed under provisions of Chapier 9 Disp. —Room Air Cond. — REG.NUMBER� Class. � '(commencing with Seciion 7000)of Division 3 of Ihe Business DISTRICT NO. PROCESSED BY a.,,' I and Professions Code,and my license is in foli force and effect. Pa�+'er Apporatus&Large Appliances �� I � I y7� � Size 8 Type HP.KW,KVA,or KVAR ( V I .License N mber ����� Lic.Class_iC�_ Up ta I Ind. FINAI � � '2,—tl:� Over 1 to 70 ind. DATE yp��DATION � Controctor r ` Da�e —� pver 10 to 50 Ind. FINAL [i! � -❑ I am exempl under Sec. Over 50 to 100 Inc BV a,� {�n,(�A � � B.RP.C.for ihis reason Over i00 � I � Dote: Services,Swbd.,MCC&Panel6oards � �:�s e ee�o e�? � � � 0-200 Amp.Under 600 V f Signature 201-1000 Amp.Under 600 V I A ��25,50 � ❑ Over 1000 Amp.or Over 600 V � �• �2.:1.v Q'.�`� Ezemption for Reg.MainL Elect. SINGLE FAMILY �Tem Power Pole&A urtenances � � � R � HOME OWNER-BUILDER DECLARATION P� PP � .C�`•J b � Sign with One Bronch Circuit � i t e oy oii ir�n ii�oi i o n exempi irom the Coniracior's license qddi�ional Sign Bronch Circuils Law for the following reason (Section 7031.5, B�siness and i Professions Code): ❑ I,as owner of the property,will do�he work ond ihe Misc Conduits&Conductors structure is not intended or offered for sale(Saction Other(See Comple�e fee Schedule�_ , 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm ihat ihe�e is o consrruction lending agency for the performance of ihe work for which this permit is issoed PERMIT FEE (Sub-Total) �� �- (Sec.3097,Civ.C.). � PLAN CHECKING FEE Lender's Name PERMIT ISSUING fEE J' �G Lender's Address � � � F'certify that I have read this application and stale thal Ihe TOTAL fEE _1 I above informotion is mrred.I agree lo comply wilh oll County or inonces and Siate laws reguloting EleUriml wiring,and he e y oufhorize represenlotives of this County io enfer upon I ihe ove-menti ty ins�ecrion purposes� e � y �� SEE REVERSE FOR E%PLANATORY iANGUAGE Signature of Permiltee Da�e � , , � � 1 j � t , _ \ �i - . .: 't 4 �`� �L s'{ '�. ..� �` - .., . , . . ` t`;�t ;.', 3 �:� i t � � .: �� � '�� ' ,,,,...� � . � l 1 i ,� tk \ ,` <i� 1, 'i� � '�t ;� l � „ . �' �,x.t ;'�t6 � ,!. ' ` ' t l� � . t' '�� �� 'r` ,x •l` t';a'. �;} ' \ 1 't 't � . � '\ ,J'c�' . �'R'�•' `i;' '":,,'t,,. .:,:, ,S F`', �� ' `t ;` �r �", t . t y .t , i �` '�, � ' h � F s � �' �' ��' s 1 . � ' �.�', :! ,` '+� }:i � :` ''`� '� j � L��{` , ,;� 4 ` �`S ' ; `; ,, �l ;` �, ` � �1 ; � , . a �j :t` '� � •f� , . � , � �t ,��k...»h4 t ,b '<�� ;� �� '. '1 -.i� ,., t ' ., .ti t �� � �r � �` "; r '� �t a. f '•i �.;.,,=y„' ' ,'� , �' , `,,i •}t � '.`, ��};4 � �� 4' ', ''�i--•r,.�.._� � l l� `f • � '. �'y� �� � . �; ' , � { �� ��� � -�� '� � i � \ t � 1 l ��,�� :i , y'� t � i i 'l ;� ,� '` ` ;! � ;� � y� �� t � �. '�.� �. �.� :� �'` �i �4 : �;� .� 1 �j . , } � �� d� , i . k� � t ` �'i� �, y . ` , . , .�` i '4 � ' ''�` . . "°_lS�i '� tr ` � ?� • ,j �, •�'' ''i � �i' '� '',, `l ia 1 ';�, � � 1 t �� ! � .it, �y ,g t` . �t� �4 F i �`11 ,`1 ',, �` ' ` Y_ _ ' . . y %i � .,` i ��;` ��1 j . ��C . .. # , �� t 5 t : t *� s � �',i • � 5' � �' '_ � `� 1 ,1� `�� i � }'; .,s �� �, f '` 1,� 1� ,` `•, ��`1. , `l 1, , .` ` t} •t ' ,V � a,� ,,`� . .` ? '.�` � �� °t''� �,�',. �� ,s�6 '�c `•'e r �;,t . 1 5 j1.' �,, (}i ,`,` .� � •;, c . . i s �,� j� �,� �,�'3 � i`. c �� 4�;�� ��F f ' .',t � i ",i � � ;y � f `�i �; � �'. '� _� ; l `` }4 `' �:, . t ,_ „ '`'� 5'q . � e4 ��'E ii �` �� { y� .. p.. "' .'7 P:.�f' . �'-� q . :6 ;A; 1 i,t •''1 �:.� j `` i� ;`.i , l �` �,�� y;AJ�,� �„ , , (m`S}"' �� � � ,°' � �� � j , G,',� :' �z., . , ,: `Vt ��' 1 � 5�' Y�S ��' . ... � •� �t`. Yf) L'y . ... >.' _S.+�J' . P!�, ' a'x j : �S ' ... �. ^:t . ". '� ` .a; `z a. _ , y5.. i •� i, 4 i ' .r C> ., .5 i"', , », M 7:. - d �t:; ? " �%c. _ ��Y�:� y��"-;' F •,�� �"� .:.&,,''i( ��'• yu . � s . . ..,�i.; .. �• '�F' 'I.` ., •� P ,,� . e i a �✓ Y' a � ' t ' . � .. .. ;.� � .. � . ; ", q` :Y ..�. . y, t � :� . . , 1 '.' .��.. � K -'".,"M1 'q. � `.i ' 'n 4.^ 'i.N ��_. �'i�S f: } 'Cy �"1 O�J. ;;. � " J v. . ... �•,,�,� _ � . � s ;vy �a �r ... �:.:�ti. � ,... �' . t � . r. ..+s . :,>" _.. :r . . ,.,�� , -.: ... _ � .r;' t , , :,- .. .., t'• ,. _ ' � .. . .. .. ,, , . ,. . . .. , -, „ . � � . . �'a. p ..,, m %� u . `��i' 'A r:. , c: �:^a-� . � , i . ' ' � 't ;', s� "�� ,z ���. -�.� �;...��t�� �� _ +2 �. '��l �. ; , _ _ , �. ,,; .._ wa . ,. — - , .. � i �'� .� � ,�. � . „ r _ . � � � .t) �.:�iy _. �') '9:.� 'p :. - ''l. rt�� S.^.Yi,Y~ .'� '`�p Cj � `l ` 1 ��5.•l � K•;� e,�t. .. -' � r� ~ , `�'• �,�z � ` " ' , . `',i ri - � ��,Q :� �"S Jy v f� r^, � � . ' �'t �� i :.��m'� `Y.: : ��^ _ � ��<�'�-M1 .; ��3. ��w 7 .•.Y�:;s�_ � ,` � VP1„�� . �'~h � ' �, ; .. ...r}_,'� ,r. .1 � ` A: � �c) 2 ,y �� 'w � '�'- �� .. � . �,, 1i. � , .._ � _� ...: - " =': �a�Y_a^c: ,.� �a ,`� µ � . , �V 'i : � r;�''� ty i; �� �� � ,a° �. � _ , .� ,i ._ � :1. „ > _ C,,ii �'7 ,,,,-�-" �\ ., " � _ � '}- , ` . , ' `� �- W� ��' ? '� ,, � a„r.� �y t, rt3" A 'J'_ �n v _ z . � t�lt�: t� ..t t,.. ..�,ry.�-µ 'f� .� � � �Jl��.,.� � . `� �� �,,.� . ; ,,.. r"r . " `i•��+�.r' ,.��"i ,..�,I -//�' �.I O"f�'/'`