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HomeMy WebLinkAbout0131A WORKERS'COMPENSATIONDECLARATION �aA�� �o�e, APPLICATION FOR ELECTRICAL PERMIT � I hereby a(firm that I have a certifico�e of consent to self CE-B06G insure, r a ce��iiicate of Workeri Compenso�ion Insorance, COUNTY OF LOS ANGELES � BUILDING AND SAFETY or a ertified copy thereof(Sec.3800C,lorb.fCI..,),�,._ � �, i olicy No. Compony—d/'T/�r v� FOR APPIICANT TO Flll IN ��B a �� I G� � Ce�tified copy is hereby furnished. EACH NO. FEE A �RE55 . New Residential Bldgs.8 Pools ertiiied copy is(ited wilh the county boilding inspeo- 1 8 2-Family,Sq.R. s — S LOCALI Y � ian department. Mulli-fomily Sq.FI. — NEAREST CRO$$$T. Residential Swimming Pools OwNER OR •� Date Appii[ont /� �J iIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets-RecJ_[_Ligh��!Sw.� �'�� COMPENSATION INSl1RANCE First 20 A�DRE55 (This axfton nead nof b.cemple»d if th.work involvad by To�al No.� Addiiional CIN Tel.No. tA�p�rmit(s for o�o hundr�d dollars(Z100)or Iss�.j a�aN CHECK I cerfify that in Ihe perfarmonce of Ihe work for which ihis PPIICANT ' _ permit is issved,I shall not employ vny person in any monner _ so as to become subject to the Workers'Compensotion taws. lighting Fixtures � First 20 ADDRESS � Totol No.� '�`dditional Date- opplicont CITY Tel.No. NOTICE TO APPLICANT: If, after mokfng �his Cerfifitote of Fixed Applionces Not Over 1 HP PERMit E�emption, you should become subject to ihe Workers' Ronge_Heoter_D.W._ APPIICAM r Com�nsnHon p.ovis�ons of rhe Labor Code,yov mvs�forth- Oven _Orynr _W.M._ .O• O b with comply with svch provisions or this permif sholl be Top _FAU —W.H.— �1 deemedrevoked. Hood _Fan _Other_ ��N Te t� � p` IICEN$ED CONTRACTORS DECLARATION UCENSE R � I heraby offirm thot I om litensed�nder provi:ionz of Chapter 9 Disp. _Room Air Cond. — y p� CIaSS. O REG.NUMBER (commencin ith Section 7000)of Division 3 of Ihe Business DISTRICT NO. D 8Y p�,' � and Profes" n Code,ond my hcense is in full force and affecL Power Apparotus 8 large Appliontes � Q /"� Size 8 Type HP,KW,KVA,or KVAR� , U — license um v LiC.Class �+ � Up to 1 Ind. � FINAI . d.' -_ Contrac� Date Q Over 1 ro IO lnd. DATE . �Z'3�� VALIDATION �. ❑ .Over lO to 50 Incl. FINAL U I m exempt�nder Set. Over 50 to 100 Int. BY � O: Over 100 � 8.8P.C.for�his reason . Z — Date: Services,Swbd.,MCC 8 Panelboards � ._ 0-200 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V Over 1000 Amp.or Over 600 V �Q� �j.� {� � �`Exemption for Reg.Maint.Elect. , , SINGIE FAMILY Temp.Power Pole 8 Appunenances �� � ��� �2 HOME OWNER-BUILDER DEGLARATION Sign wi�h One Bronch Circuit �� • •4 7.2 5 I hereby affirm tho�I om exempt from the Controc�or's License Additional Sign Bronch Circuits Law for the following reoson($ection 7031.5,Bosiness and y'e •4 7.2�� . Proiessions Code): � � . � Misc.-Conduils&ConduUors . I,as owner of the property,will do the work and the '����,�1 8-8 b , struc�vre is not iMended or oife�ed for sale($ection Other(See Compleie Fee Schedule)_ , � 7044,Business and Profeszions Code). CONSTRUQION LENDING AGENCY � 1 here6y affirm�hat there is a consfrucfion lending agency for the pertormante oi the work ior whkh ihis permil is issued PERMR FEE � � (Su6•Total) 3 � - � - (Sec.3097,Civ.C.). ' PLAN CHECKING FEE � � � � tender's Name � i PERMIi ISSUING FEE � � - - Lender's Address � I c �y thor I have read this applimfion and srme fhm fhe TOTAL FEE � ?2 •� ab ve i formation is correct. ree fo comply with oll County � � o in es ond Stat gulating Electrical wiring,and . � ere uthori entmives of fhis County to enter upon � � e-m ed properfy for inspeciion pur ses. j , �� SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ure ef Perminee ate �� � �, `�/�. �'. . . , . ,~ � � `�, ��? - �\ '.4 l, .�� r_w 1 _ / J • ` `` � n� - ,�, � , \ • � `` f,� \ � 1 . , � �..i-, ��, ,i�y�!' r r \� 1 � � 1�� 7--� � '��i _ �. 4� � , _ �� � _ ��' � ._..�'� M ��I. � . �;' l ' % �.✓ i `' '�„�" �, �"�`; r', �i � \ � (� Y �, +' ' � ' � � � � �� �� a O,','9. � . ' ,- < �> '%- + � ��... 'C. O � =' 'G� � �.�'o � � � . �. � , ',l y ,Z � �4 � �a . � � ,% '} ,� `t.' f"f''' r�Y �.O q � � � �� � � JQ�� . :"' v, �.� � t `�; �� � r ! �:! 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