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HomeMy WebLinkAbout1142A 140RKERS'CO�IPHNSATION DECLARATION 76A663 APPLICATION �FOR �ELECTRICAL P�MIT � {� CE$�6G(2-80) t here��y atrirm that [ h�ve a cenificate oi cunsent to sulf COUNTY OF LDS ANGELES BUILDIN AND SAFETY C J insure,or a certificate of Worke�s'Compensation Insur;mce,or a certified copy thereof(Sec.3800,i.ah.('.) ����y� ��!"��"IJ FOR APPLICANT TO FILL IN J06 � � Yulicy N '!, mpamy�rG 1117 — EACH NO. FEE ADDRESS�� � New Residential Bldgs.&Pools - � Certified copy is hercby fur 'shed. 1&2-Family,Sq.Ft, S — 3 LOCALITY��Q Multi-familY SG.Ft. NEAREST �CertifieA copy�ic filed with h county bi'ding inspe io CROSS ST department. Residential Swimming Pools OWNeR OR �j/ 2�Q��I FIRM NAME�*_ W. Date.�_J�__Applicnn Outlets:Rcc.�Light_Sw._ ' MAIL Fust 20 —._ __. ADDRESS ��__ C7(R'TIFICA'fL•'.OP IiXlillP ON FRUM WORKERS Tp[al No.'.—__ Addiuonal CITY Tel COMPI�;NSA"PION iNSURANCL•' ��: � PLAN CHECK .q� �/�� + � APPLI_CANT w�N�(_�� C)� (7'his sectiun need not be completed if the work involved - U by thc pc[mit is for one huvdred dollais (5100) or IessJ Lighting Fixtures First 20 aoDaeSS/,,�j Q� �` , Total No. A�ditional _._ _ `�!�.��++ '^ � 1 certify that in thc perfm�mance of the wotk for which this Fixed ApplianCeS Nol Over 1 HP CITY TeY . .�81 0 permit is ixsued,1 shuil nut employ any person in any manncr PERMIT � �� W s'o as to becnme subject to the Workers`Oumpensation La�vs. Range__Heater_D.W. APPLICANT p'—'n � Oven _Dryer_W.M. _ ADDRESS721 _y�pyp(Yw1 �7 � ToP --FAU -----..__ L4l�1MIY � UaTe .lpplicant_ —W'�'— �.f.'� Hood_Fan _Other__._.__ CITY Teii,p�.�Q�/_ T _ t�7�/ 4 NOTICE'.I'O�1YYL[CAYT:[f,after making this Certificate of Disp. _Room Air Cond._ ___._ _ _ LICENSE OR- +�� F.xemp[ion, you sliould becnme suhJect tn the Wurkecs' REG.NUMB � � Clas�� Cbmpensatiun prnvisiuns o£the Labor Code,you must forth- powe�Apparatus&l.arge Appliances �ISTRICT NO. PROCESSED gV �a�ith comply wi[h such provisions or this permit shnll be �I— Jeemcd revoked. Size&Type HP,KW,KVA,or KVRR I� ��` Up to 1 Incl. ___.__ _ � � FINAL OVe.Y 7 t0.70 InCI. DATE - CdCENSED CONTRACTORS DECLARA"fION Over 10 ta 5D incl. VALIDATION . 1 hercby affirm tha[I em liCen.eed under pmvisions nf Chapfer Over 50 to 1D0 Inc. -- — FINAL � BY � 9 (emnmencing wifh Seciion 7000)of Division 3 of the Busi-' Over 100 ness and Professinns Cudn,nnd my license,is in Tull Torce,.md effect. �[����Q r_ Services I License NumneF,�� Lic.ClassLF�� �C���P 0400 Amp.Under 60D V � . ^ Q 201-7000 Amp.Under 600 V ' Contractur� Date �Of' ' C7� Ov2r 1000 Amp.or Over 600 V __ __ `;� � 4.ry�F HO\?E OWNY:ii-BIiILIR�,R DI(C7.ARA'fiON Temp.Power Pale 8 Appurter.snces �r c a c • •G Sign wfth L'ne Branch Circuit --- i hereby affirm Ih�[ I am excmpt t7om the Contrac[or's qdditional Sign Branch Circuits � e a o q,� p License Iaw for the folluwin5 reason(Sec�ion 7031.5. Busi- ness and Professions Cnde): q,),� ��. Misc.Conduits&Conductors ° s ° � � I, as nwner oT the property,will do the wurk and tho Other(Sue Com lete Fee SchedWel— siructure i4 noi intenJed i oCfered Fur xale (Section p f��2 a—'8 I 7044,Business and Professions Code). CONSTRUC'I70N LENDING AUliNCY [ hereby afFinn Ihu[ �here is a construction lending agency fnr the perFormance uf the work for which Niis pennit is pERMIT FEE (Sub-Total} '„�� issuCd(Sec.30)7.Civ.C.) Lender's Name_ — pLAN CHECKING FEE (One-Fourth Permit Fee1 LendePs AdJress � �pERMIT ISSUING FEE I certify that I have rc�d this;�pplication and state that the I TOTAL FEE above in}brmation is correct.I ugroe lo comply with all Coimty o innnces and Sta(e la�vs regul� ing F:lectrical wiring, anJ h r y uuthnrize re •esen[atives o liis County[ enter upnn th•a uve-mentione c ty foc i �ect o poses. ykl?R@VIRSL'P'OR EXPLANA7'ORY LANOUACR �a.ag.0[ Si nuture of Permittee Date , �. � . , , � t + � � � � � � � t I I .� � � �r.l.e 4....'� � 3.• x:..` . . i I i � f � ; � I i � r S � F' ! ! , F�, _ . � I I � ; . �' ; I ,�-� ; �:" ._ � i ; f � I r'' .� _ � i i � � I ;. i'� A j .. '+ r'. ' � � � � � �' �a �.1. ( � � � � � � .�'� � �,�3 �' , , ' ' , _. 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