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Home My WebLink About1338A (7) WORKERS'COMPENSATIONDECLARATION � 76a663 ,o�e� APPLICATION FOR ELECTRICAL PERMIT � I hereby affirm�hat I have a certificate of.toosent fo self �"� . . . ins�re,or a certificate of Workers'Compensation Insurance, COUNTY OF LO$ANGELES BUILDING AND SAFETY or a cerlified mpy ihereof(Sea 3800,La6.C.) - . P❑olicy No. � Compony iOR AAUCAM TO flLl IN . JOB � �1 � . Certified copy is he�eby furnished. New Residantial Bidgs.8 Pools EACH NO. �FEE ADDRE55 �11�/ � � 182.Famil Ff. E � — E LOCALITY� . Certified topy is filed wifh the county building inspec- Y•�• rIFnREST tion deportmen�.� � - . MuNi-family Sq.Ff. - — Residential5wimmingPools � GrtoS557. Date Applicont . . , a � OWNER OR j`��A"'�—' , FIRM NAME CERTIPICATE�OF EXEMPTION FROM WORKERS' Oufle :h Ret—lfght_Sw._ - �"�� COMPENSATION INSURANCE � � � �nDDRESS - Thfs sMfon need nof bs com lefed if ths work Involved 6 First 20 � ( P Y Totol No. - CITY Tel.No. fh.P�rmif is for oe�hundr�d dollan(5100)or Ins.) Additionol I certify that in the performance of'the work for which this . � _ . � qP�PL�iC�,c,NT� � � � permit is issved,I shall not employ any p on i y manner . so as to betome wbjecl ro the W� o pe s 'on Laws. Lighting Fixtures� First 20 ADDRESS� � Total No. Additional Date_�;�ApplicaM CITY Tel.No. NOTICE TO APPLICA T: If, ofler makin this e�li i �of Fixed Appliances Nat Over 1 HP PFRMIT . Exemplion, yoo should 6ecome subjetl �o the W ers' . Range_Heoter—D.W._ APttiCa'M , Compenwiion provisions of the Lobor Code,you must rth- Ovan._6ryer _W.M._ ADDRE55 � � rv�,� � with tomply with svch provisions or this pe�mi� sha be .Top _FAU —W.H.— . deemed revoked. � � - Hood _Fan _Ofher_ - CITY Tel.No. ' . � � LICENSED CONTRACTORS DECLARATION uCEN - �I hereby oHirm tha�I am licensed under provisions of Chapier 9 Disp. —Room Air Cond: — REG.NUh�eeR - - - Clau. (commencing wilh Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances . . DISTRICT NO. PROCESSED BY �, and Professions Code,and my licanse is in full force and effed. - - �� - � p� ��r}-� � � Size&Type HP,KW,KVA,or KVAR� Q License Number��2 Lic.Class� �� FINAL - � V � Up to 1 Ind.� DATE ✓ra- � '��',Q� Over 1 to 10 Incl. . �� lJ � VAUDATION - Q Conlmctor� Dme� Over 10 fo 50 Ind. FINA � . V ❑ I om ezempt under Sec " � � � Over 50 to 100 Inc. . BY�� , ,�± �f . . . s++ B.BP.C.for ihis reason �°e�� . u�`t�� 2 � � �ate: - Services,Swbd.;MCC 8 Panelboards ► � -� � . � - — ' 0•200 Amp.Under 600 V - Signafure � 201�•1000 Amp.Under 600 V � � - �� , . , Over 1000 Amp.or Over 60D V . � Exemption for Reg.Maint.EIeU.� SINGIE FAMILY . Temp.Power Pole 8 Appurtenances � . . - . . ' HOME OWNER-BUILDER DECLARATION Sign with One 6ronch Cirtoit . - . I hereby affirm that I am�ecemp�from the CoNracror's litense Additionol Sign Bronch Cirtuits -� -- - � Low for rhe iollowing reoson(SeUion 7031.5,�Business and - �- � Professions Code): . � � � M:sc.Conduiis 8 ConduUors - , � �� J�$A— I,as owner of the property,will do the work ond the - � sirocture is nol iMended or oHered for wle(Section Ofher($ee Complete Fee Schedule)_ � _ . . , . ,�,• •-o • •`� . � 7044,8usiness and Professions Code). � . . CONSTRUCTION LENDING AGENCY �� - - � � �3 a�� I I hereby affirm that there is a constrottion lending o9ency for � ��• •3 Q 5.0� fhe performante of fhe work for whith 1hi5 permit is iSSved � PERMIT FEE -- � �� - -'� ($ub-Tolal) �� . - , (Set.3097.Civ.C.). . � . . . . � � .. . , - PIAN CHECKING FEE� - . . . . . . �2 O� �8 4 , . lender's Name � � � � � � � - - PERMIT-ISSUING FEE � Q _ . .. ._ ._... � Lender's Address � � � � ' I certify ihoi I have read this application ond state Ihat rhe TOTAL FEE � � Q,Se . . _ � obove iniormation is correct.I agree to comply with vll CoaNy . . . � ordinances and Siate laws regu aling Eledritol wiring,ond � � , . � reby �horize re ntaf i ihis County 10 eMer opon �. � . - � - �� 1he o6o e entio d pr er ,f inspedion purposes. � � � SEE REVERSE FOR EXPIANATORY LANGUAGE Signo ure ermi ee � Date � � , � . � � J . t, . ; . _. ', � � , - � �� . ; � ;� � � � � . .1 . . . ', , � � L � � q { "� ,� � Z � r �L G Z "�S N � b . 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