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HomeMy WebLinkAbout0897A (6) i WORKERS'COMPENSATION�ECLARATION 76A663 i0i8t pppEiCATtON F4R ELECTRICAL PERMIT /� 1 hereby affirm thot I have a certi{icate of consen�to self CE-806G ry' insure,or a certifimre ot Workers'CompensaHon insurance, GOUNTY OF LOS ANGELES BUILDING AND SAFETY �� � or a certi4ied copy thereof fSec.3000 Lob.C.) U Policy No��tl�mpan,�.�t�►ti�n ��� FOR AiPUCANT TO FN.L IN DDRE55 � � 1 � Certified copy is here6y furnished. New Residential Bldgs.8 Pools EACH NO. fEE � O s = g LOCALITY m Certified copy is filed wilh�he counly building inspeo- 1 8 2-Fomily,$q.Ft. 1 lion deporfinent. � Multi-family Sq.Ft. CR�55 ST � Q1` Residen�ial Swimming Pools OwNER OR I Oate�I��Applicani �� FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ ��� ' COMPENSATIOhI INSURANCE ADDRE55 M �� First 2(1 � (Thls s�elion nwd nol l»complN�d if th�work involv�d by Total Na. Additional CITY Tet. tho p�rmii is for one hund��d dollon(;100)or loas.) PIAN E I certify�hai in tha perfarmance of the work for which this AV�ICANT � permit is issued,1 shall not employ cny pe�son in any manner so,r•�o becoma s�bjaci to the Workers'Compensation taws. ��9�'ting fix�ures Firat 2D _ AD�RE55 � Addiriorro4 � Totol No. CtTY Tel.Nn. D^te APPlicanl Fiaed Appliances Not Over t HG pERMIT 1 ' � �ICE TO APPLICANT: if, after moking this Cerfificote of qpp���� ..:mption, you shoold bemme subjed to �he Workers' Range�Hcater_D.W..— Compensa�ion provisions of ihe Lo6or Code,you must forth- Oven _Dryar _W.M.— ADDRE55 with mmply with such proviaions or fhis permit shaif be 7op _FAU —W.H.— deemed revoked. Hood _Fan _pther_ CITY� , Tel.N � IiCENSED CON7RACTORS DECLARAiION uGEt�uSE OR � C'�s i t ,�/` t herehy dHi.m that�om licensed�nder provisions of Chapte�9 Disp. _Roam Air Cond. _ REG.NUn�eEk � `!a'r"f ��Ou•t..G�7 (commencing with Section 700pj of pivision 3 af the Business DISTRtCi NO- PRUCE D BY � ord Professions Code,and my license is in futl force and effeci. Power Apporatus 8 Large Appliances � ,i Stze&Typa HP,KW,KVA,w KVAR U License Number Up to 1 fncf. FINAC Z.�,�Z,��'"F7lk.Class d.' /jhlL,���� ,�� Over 1 io 101nc1. DATE �� c x VALIUATION � controUor I/ L Over 10�0 50 Intl. �C�� � � ❑ FINAI W � 1 am exempt under Sec, Over 50 to 100 Inc. BY d B.BP,C.for this reasan Over 100 Z Services,Swbd.,MCC 8 Panelboards � ; Dnte: p_ppp pmp.Under b00 V M SignaWre 201-1000 Amp.Under 6W V � Over 1p00 Amp.or Over 60p V `xemption for Reg.Maint.E1ecr. ` SINGLE FAMILY Temp.Power Pole&Appurtencncea �' HOME OWNER-BUILDER DECLARATION � f ' � Sign with O�e&anch Ckcuit � � 1 hereby aHirm Ihat I om exempr from�he Conhoctor's ticense qdditional Si ng�nch Circu�, _ Law for�he following reoson(Section 7031.5, Business ond �,," �('��i�9�� Professions Code): t� C �Q$9�7 A ❑ I,as owner af�he property,wili do�he work and the Misc.Canduits&Conductors Other See Com lete Fee Sehedule_ ���� • �� structure is not intended or offered for sale (Section � P � � 704A,Business ond Professions Codej. � � �3 a 5 Q CONSTRUCTION LENDING AGENCY � ` ' � � 1 hereby affirm�hat if.ere is o mnstruUion lending agency for ��2�����U the performonce of the work for which ihis permi�rs issued PERMIT FEE (Sub-Total) " � (Se[.3047,Gv.C.). PLAN CHECKING FEE Lendar's Name PERMIT ISSUING FEE Lender's Addreu I certify tho�I have reod this application and stare that the TOTAL FEE above informa�ion is mrrect.I agree to comply with all Coun�y ordinances and Slote laws regolating Electricol wiring,ond hereby a�thorize represenlotives of this Covnty to enter upon the obove-mentioned p�operty to� nspecrion urposes. SEE REVERSE FOR EXPLANATORY 4ANCaUAGE I �J.ac'!C� I�` t� ��2.n�54� f Signat��e of Permi ee �— Dat_-e�� . .— �. p�' � O�,-"� . � � V.aw u c p� 6: 0 � [ c� c .:.�y O.N �=is V�t7 '" n c -- c oy �, '�s � �'r 4+ n � C ;t . U 4".�C'A i1-� C �\ . d -d 6 p 61 'G . Y ��u N ..a.. Q O�a. 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