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HomeMy WebLinkAbout0917A (4) WORKL•RS'COMPENSATIONDECLARATION �sA663 �APPLICATION FOR ELECTRi�AL PERMIT {� - CE�806G(2�801 1 hereby aefirm that 1 have a certiflcete or consent to se�r COUNTY OF LOS ANGELES BUIIDING AND SAFETY Ll insure,or a ttrtificete ol Workers'Compensation Inaurance,or � � � a certified copy thereof(Sec.3600,Lab.C.) ,,.,�7 ��� •�. -{�—/� �' FOR APPLICANT TO FILL IN J00 » � � Poiicy Na.ZL.L=L"'Company���/"� �"4"� New fie5identiel B�dgS.&POoiS EACH NO. FEE ADORESS �1� e��J�g'� 1t76 � � Certified copy is hereby furnished. 1&2-Family,$q.Ft. $ — s LOCALITV � Certified copy is filed with the coun[y building inspeCtion Multi-(amily Sq.Ft. CROSS ST �/y depertment. � Rasidential Swimming Pools OWNER OR ��� � fIRMNAME �h� A� R G Dale �I ApplicaM �� �"� Outle[s:Rec._L�9ht_Sw._ MAIL Firsl20 ADDRESSY d ��'� , CERT[FICATE OF EXEMPTION FROM WORK[RS' Total No. Additional CITY �(; T•i o.� >�y� . COMPENSATION INSURANCE � ' �' � , PLAN CHECK a ' � APPL�CANT � ' CThis section need not be rnmpleted if the wort involved Lighting Fixtures First 20 ADDResS by the permit ie for one hundred dollua (SI00)or Iess.) - � Total No. Additional � . I certify that in the performance of[he work�for which this . CITY Tm No. . � � Fixed Appliances Not Over 1 HP permit is isaued,I sheil not employ any person in any menner pERMIT V ��, so as to become subject ta the Workers'Compensation Lews. Renge_Heater_D.W. APPLICAN -f Q, N - . - ' � Oven _Dryef_W.M._ ADDREs��� ��j��< Z Uete Applicant� Top _FAU _W.H.._._ . GTY TsINo.9�/� ����') � Hood_Fan �Other_ , NOTICE TO APPLICANT:If,efler making this Certificete of �Disp, ___.floom Air Cond._ LI NSE . � � Exemption, you should berome subject [o the Workers' � REG.NUMBE � Clas�EG1 � Compensetion provisions of the Labor Code,you must forth• Power Apperatuf&I�rge Appliances OISTRICT NO. PROCESSED BY �, with comply with such pro�isions or this permit shall be Size&Type HP,KW,KVA,or KVA � � .r , deemed revoked. . �� � �/'��"" ' � . Up t0 7 Incl. ' FINAL over 7 to 10�nc�. oaTE / �� ��/ VALIDATION UCENSED CON'iRACTORS DLCLARATION � Over 10 to 50 Incl, Ca �' I hereby affirm[hat 1 em licensed under pwvisions of Chapter Over 50 to 100 Ina FINAL ' 9 (commencing wifh Sect�on�000)of Division 3 of the Busi- Over 100 BY . ness and Rofessiom.Code.and my ficense is in full force and � u"��_ , effect. Services � License NumbeQ.�� Lia Class � 0-200 Amp.Under 600 V . . � �� p f 201•1000 Amp.Under 800 V ContracldyL�L_.�'�± Date f/ Over 1000 AmP.or Over 600 V '. '091.7Fl HO�IE OWNER-BUILDER DECLARA710N Temp.Power Pole&APpurtenances . �2 I hereby affum that I am exempt from the Contractor's Si9n with One 6ranch Circuit � � ��� License Law for the following reason(Section 7031.5, Busi• Additional Sign Braneh Circuits � s'•�C.Jr C . ness and Yrofesaions Code): , . . . Misc.Conduits&Cnnductors � !^'a�Q J(i cz.' � � 1�, as owner of the property,will do the work anJ the Other(See Complete Fea Schedulel— e ' structure is not intenJed or offered for snie (Section � . . �j���]-�� � � 7044,Husineu and Profeesions Code). � " , � CONS','RUCT]ON LENDING AQENCY . . � 1 hzreby affirm thet Ihere is a construction lending agency ' . � for the performance oP ihe work tor whkh this permit is pERMIT FEE � (Sub-Total) � issued(Sec.3097,Civ.CJ. Lender's Name PLAN CHECKING FEE (One-Pourth Permit Feel . Lender's Address pERMIT ISSUING FEE . O � I certify that f have read this application and state that the TOTAL FEE . y�0 ,�d ebove inFormetion is wrrect.1 agree to comply with all County . � � ordinanres and State lews regulating Electricel wiring, and " . hereby aufhorize representatives of this County[o enter upon . � • the above-mentioned property Por inspection purposes. . SEE�REVERSE FOR @XPLANATORY LANGUAGC � /h-t���. .sLLr' , Signature of Yermittee Dete . 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