HomeMy Public PortalAbout5452 LOMA AVE_Electrical__ y' JJQfj,XERS'COMPENSATION,DECLARATION;.•, ? ',7,sA6s3'. ' ioi8,1' ������A4�®p�p� �®�''����^�®��qp. ��®p/a�g'
''.Fin eby affirm that I have a certificate of consent;to§elf'insure� 1'CE.BosG_j' N `�.r {r9 PfilL_ Y-I�-VA •U,, „ m , � 3,•
or` ;ert,ficate of Workers' Com ensation Insurance,.or.a certified'; ;''' t�,^ - " ?c , y, a
P z _ COUNTY OF LOS ANGELES � BUILDING,aAND,SAFETY
0e' thgreo�j Secj800,Lab•C), .,
Po Icy N7� '," OF , Ti/°i" /.(� t FOR APPLICANT TO,FILL INT' i.
Y Company �t a. «a)JOB^
Gertifled copy Is,hereby,,furmshed V " ' 1 EACH NO. "FEE,,,," (ADDRESS •'f, 'r '. *f' �� �,:, Y`
k r•, ,�,= LL, s• f,New Residential Bldgs & Pools -,-,1,-
f > $, — $ j LOCALITY"
)Certified,copy�is�•file is with' the`°counfy'fiuildiri_g,inspection 1 & 2-Family,Sq Ft +�✓
department _ •;�„�, 'q .'t Y 4 (NEAREST:
it s Multi-family S Ft
$� '� •" h. ' ;CROSS'ST` d
moi=y6= „ ' � -Residential Swimming Pools ' (OwNER OR F;•'
'e �iDate "AppIcarit t r' ,. �,', ,a ;,,e'�a',i' "?' 'y: t✓C'qtr r
`,"�'i;.a ”'r fi'" - ,,1's • . E' •>.' - si FIRM NAME-:.
"CERTIFICATE+OF,EXEMPTION FROM WORKERS 4 i. ,n MAIL,,'
Outlets,Rec�,Llght'—,15'� ;ti' e • y
:�,'yA'ti "`,COMPENSATION INSURANCE M`' - '; , - �' U: ',4 43-ADDRESS r -'„ .�
. , :.1�: First 20' Z
;(Thlssection need'not be`completed'if involved-by the r'r,�Z-,. i• CITY ' Tel No
permit Is for one hundred dollars.($100)or less.) t ," Total`No'= ; Additional' �1 �r,`a a�,
•x'' i j,. t',(• , �. ,-•, h' k. •y' - -r 'PL'AN'CHECK_' ',d �^ "
•'<gl,Certify„that n the�,performariCe'Of„t e,wOrk•fOr wFuCh-,this perm(t ,y ,,i• ,�� } •- - �'tj tir •S -�-•-•q-r {•APPLICANT "y.;'�",,�' _I` ..,�.' +•� d. -^ - a
rvis�;issued, I�shall.not employ.any,,person•iniany�manhi;644 o.as to "• ""''� �t� a
.,Q-become subject torthe%Wofkers',CompensaUon Laws'Y„i r�F ".'t y,Lightin6 Fixtures First 20-,., �• 0 ADDRESS; •. f: ? ;' r �,, �i'
m a t• _
�% Additional
�`�` I`O,•'F i ct. °r' ;'� h2, w, 5` 5 ri „TotaI,NO �t''�a, ;r, r •t ti yCITvY'; i �r -,••yam 'Tel NO
Date Applicant'�•,,� _ ,' n w
w ' Fixed Apphances.Not Over 1 HP _ "' 'PERMIT;
• l rNM,CE TOS-APP,LICANT,• If„ after-, making`fthls, Certrficate,-of • 's 'r'' '. ,Heater t"!”,�DW ° ” s � �3 ,f APPLICANT �� `,•
�y Exemption;youshould btecome subject to�the Workers',Compensation , •�_ Ra ge y J �- r�'"
P , e' ��' ' e-W-§S, " rs 3
provisions of the'Lab'or'Code, you"'must forthwithtcomply„wifh such, Oven _°Dr'yer•_`WM`° ;j' 0
a,.,
•provisions or this permit-shall be:deemed revoked,= :, << ,'��, ,� Top't�'—••FAU' WH _ "�' =
,CIT,Y- el N
,�� .�,r, •.LICENSE D;CONS RACTORS DECLARATION : Hood —.,Fan', Other_+';'
. /,r/DU LICENSE OR ” <-
I hereby affir6_that'I.am licensed'under provisions of,Chapter�9� -` ,
� w. , ji , .�', -Disp-.`— ROOM Air,Cond- ! - '� _ •REG`NUMBER' �, E�;41
: :�-, ,
4(conimenci ag wdfi Section'7000)I of Division 3 of•trie Business,and ,4 r'
r.
rProfessrons:Code;and;my license is•In full;force'and effectAppliance's ` DISTRICT NO FR SSED'BYf
v x Power Apparatus'R Large, ,y £
Sizer& Type HP,KW,KVA,or KVAR
License Number �k/ /J (/ - ?t x, r , _ v
LIc Class ,Up to 1,Incl " FINAL' a
,', ', - .. N% k.-:+ �, 'r.' �t:- •• ' _ - DATE 'rx` ' ^ �`. ',', „"`�," .�
` Over 1 to 10 Incl +
'Contractor. C'LLATDate$ •°' .f ;, I �• ,�' r y x :VALIDATION' �.
+, " -Over 10 to 50 Inclr• FINAL
I,am.exempt under,Sec -„�;y ' �� 'r�” Over,50to`1;0.0.Inc'j ° gy qi ^� �r j ,W`
Over 100',, rt t r ,'n• '-� t;J,,y:g' 0.',✓
B&P C for 3his reason rt k N
2Services;Swbd,MCC& Panelboards 'r °
0 '200 Amp Under 600V ; :~• a ;� ti
a•s =,r. +h,;o• :i` 201 -1000. . yr'
Signature * Amp Under 600 V �,
y 1Psd` a-, P? ' t; y .^ti p Over'1000'Amp or Over 600 V Hn'
Exemption for Reg Maint'Elect z ,'tiw 4,
• 'SINGLE FAMILY.''' " a Temp Power Pole& Appurtenances
N °.. ,'. •HOME'OWNER BUIL'DER'DECLARATION '1;i' Y/` h y. =".. `'r•: a - '
Sign with,One Branch Circud
I hereby affirm that,I;am exempt-from the Contractor,s',License4Law - 'r A ;At(T
nal Sign B'r`anch Circuits y ;-• S „ e
for,the'follyowing reasom(Section 70315,'Business'and Professions �, _ ; n =g r
°Code)d! _�lo _ _� - i.' d ,. - '�,i• `,, y� 2T a�, J,dye -e�,ser.j Y y,• •�' ;. F , a, ,1 fi 1i '{,"'`„. •,4-j. ",h •i—,j('yy'7 ,i i ;+.f , L +'i
0 y, ar Y:.'^f 7 .�Mlsc',Coriduds & Conductors- ' zr t,_ tT, . }
'I,ras'ownen'of•the'property,will`do'the work,and the structure 7 {•' l �'hE ,O3 ,
is not Intended or offerfor sale°(Section 7044, Business ; Other jSee'Complete-Fee Schedule)-
eda. • " ;' s;,. :"• °
t . and Professlo_ns Code') }, ;' _ ,<'y {- ;D ' 7Q:
u CONSTRUCTION LENDING AGENCY' `', -ti r -- w• =,. • : ( �:�--. .:: ..-:.�0 [[[[ 7]'y
I hereby affirm that,there'is" a construction lendmg''agency,,for„ttie' r' rs.,• �1;” X ` t�tt,,�[[�' '
performance of the work,for which this permit Is issued,(Sec'3097- Sub-Total y`• j +r'.' - _ �t iVe._ 5 ., vE)
/. /� �{' I[PERMIT_FEE , �• '-�,- •( ,, '
•CIV C) °5< , , !r .1 x 1 - , --. . ' - r F. '
1 PLAN CHECKING FEE :�' " ? r "
a i u �` : .wr xi. 'tri .�y.",. . +.4-
Lender's,Name .• _ r�r s J�t�Q �JQ°�
'c Z ti PERMIT�ISSUING�FEE
Lender's Address
Iroe'tify that'( have read.this application and'state that the'above' TOTAL FEE : ♦S 'rte
Information Is correct I a ree to comply with all ` �, -m '
g py County-ordinances •� �, .r " -, "•, r ` -�`'
Viand State law, regulatmg'Electncal wrong, and 'h'ereby authonze' 't ,^
representativ
of this County to'ent upon the above-mentioned t ` "'''= ;r" 5" :"� r,';6 •;`' '
property for nspection pur 'f r -,
+ SEE_REVERSE FOR EXPLANATORY,LANGUAGE:
5i re of'Permittee Date '+ a r'; o q• -I i