HomeMy WebLinkAbout1859A 1YORKERS'CO�iPENSATIONDCCLARATION � 76A663 APPLICATION FOR ELECTRICAL PERMIT �
� � CE�806G(2-90)
,'hereby atftrm that I have a certificate of cnnsent to self COUNTY OF LOS ANGELES � � BI�ILDING AND SAFETY
insure,or a certificate of Worke�s'Compensation Insurance,or • ' .�+
- a cer�1tified co 1 e eof[(g�ec.3800, b.CJ � ' C!�
(�j/�G�C�����y � FOR APPLICANTTO FILL IN Jpg 0
i Policy No. Company n � / NeW Residential Bldgs.&PoolS EACH NO. FEE ADDRESS
� Certifed copy is hereAy furnl rG�1.�Cl7�.J�Y 1&2•Femily,Sq.Ft. $ — $ LOCALITY �
❑ Multi•family Sq.Ft. NEARE T.. � �
Certified copy is filed with the county building inspection CR055 ST�
depart ent. � Residential Swimming Poots OWNER OR �
Date�f� - �� /�� /' FIRM NAME
Applican[ ' Outie[s:Rec.,_L�ght�_Sw.L �� \ qooAeSS � � � S��
First 20
CERTIFICATE OP EXEMPTION FROM WORKGRS' Total No. � Additional � CITY s Tel No, � �,
�J ,� COMPGNSATION INSURANCE PLAN CHECK� 0
�j�/��,z� APPLICANT
/y�hu sechon need not be completed if the work involved d \ U
'by e permit is for one hundred dollazs (5101►)or IessJ -' Lighiing Fixtures 1 � First 20 qooReSS
l��p Additional � �
1 cerlify that in the performance of the work for whicli ihis � � Total No. . CITY . Tel No. .�
ermit is issued,i shali not em In en Fixed Appliances Not Over t HP
p p y y person in any manner PERMIT / �
so as tn hecome subject to the Workers'Compensation Laws. Range_Heater D.W. � qPPLICANT `G-l. a
. � � O�en _Dry¢r_W.M,_ ADDRESS � �a N
Z
Date Appllcant � Top _FAU _W.H._ . . G 7 �'G 7v
Hood_Fan �—Other_ CITY Tel No. 9
NOTICE TO APPLICANT:If,after making this Certifcate of � LICENSE OR
�isp. _Room Air Cond._ REG.NUMBE Q 6C Ciess -
Ezemption, you shouid hecome suhject to the Wnrkers' — .
Compensatinn provisions of the Labor Code,you must forth• Power Apparatus&Large Appliances DISTRIC7 NO. PROCESSE(�p eY .
with comply,with such provisions or this ermit shail Ne _ Size&Type HP,KW,KVA,or KVA � \� ���
Jeemed revnked. �
Up to�1 Intl.
FINAL
Over 1 to 101nc1, DATE � �
. ' LICENSED CONTRACTORS DECLARATfON � ,�(,i /� ,�� VA�IDATION
Over 10 to 50 IncL�.
�. FINAL
I hereby affirm that[am licensed undv provisions of Chepter Over 50 to 100 Ine. BY � � - ,
9(commencing with SecUon 7000)nf Divis(on 3 of the Busi- " � Over 100 �� �
ness and l4ofessions Code,and my iicense Is in full force and
etfect. / � � �� Services ' � . ' �
License Nu e�r�y�� Lia Class 0-200 Amp.Under 600 V .
�.` 201-1000 Amp.Under 600 V
CoMractor� Date � (J z�' Over 1000 Amp.or Over 600 V
. tiOMB OWNER•BUILDER DECLARATfON � Temp.Power Pole&ApPurtcnances � '
t hereby affirm that 1 am ezempt from Ihe Contractor's Sign with One Branch Circuit • �
License Law for Ihe following reason(Section 7031.5. Busi• Additional Sign Braneh Cireuits §f 8�9 A , �
ness and Professions Code): � , ,
� � ' , Mtu.Conduits&Conductore #• •�•�•;•2
� I, ss o�vner of Ihe property,will do the u�ork and the pther(See Complete Fee Schedule�— �
structure is not intended or otkred Tor sale (Sedion �:• �6�9 O
7oaa,Husiness and Professions Code). . .
CONSTRUCTION LENDING ACENCY - ' �6 6 9 0 d �
I herehy'affirm that there is a mns�ruction lending agrncy , �
for the performance of the�vork for which this permit is pERMIT FEE (Sub-Total) �
issurd(Sec.3097,Civ.C.). . � - . ��� 6�$2 .
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
LendePs Address PERMIT ISSUING FEE _ - � ,
I certify that I have read lhis apPlicatlon and state that Ihe TOTAL FEE � . ' �
ahove intormation is correct.1 agree to comply with ail Coimty � .
ordin�nces and State laHs reguiatina Clectrical wiAng, and '
hereby authorize representatives oP ihis County to enter upon � � �
the ahov- iton roperty for inspection purposes.
StiE'REVERSE FOR ERPLANATORY LANGUACE . - -
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Signature of Permrtte Dat . � � .
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