HomeMy WebLinkAbout12_21_1981 - 20948 MOONLAKE ST WORK&RS'COb1PENSATIONDECLARATION, � �BA663. � .. APPUCATION FOR ELECTRICAL PERMIT {j �
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-I hereby affirm that I have a certiticate af consent to self. COUNTY OF LOS ANGELES ' BUIIDING AND SAFETY U
insure,or a certiCcate of Wnrkers'Compensation Insurence,or�� - � " .
a certified copy thereof(Sec.3800,Lah.C.) �
� FOR APPLICANT TO FILL IN JOB '
� Polfcy No. Company ADDRESS, �
NeW ReSidential Bidgs.&Pools . EACH NO. FEE • . �
� Certified copy is hereby furn(shed. � ° ' 1&2-Family,5q.Ft. a — $ LOCALITY / � � , �
�. Multi•family Sq.Ft. N ARES
� Certified copy is filed with ihe county building inspection CRO55 ST.� �
Residential Swimming Pool} -
department. ' OWNER OR
�y L/., � FIRM NAME 7�' � [iL O
Date Appiicant Outiets:-Rec.LLight✓Sw.� AODRESS �L�Q �
First 20
CERTIFICATE OF EXE�1P'fION FROM WORKERS' Total No. � Additional CITV � Tel No. — L }
COMPENSATION INSURANCE . �- ,;. ' � . � PLAN CHECK a
_ -(This section need not�6e completed if the w0[k InvOlved � AP�LICANT � � ' � V '_
by fhe permit is for one hundred dollazs (5100)or Iess.) Lighting Fixtures First 20 q RESS . - � �
� Total No. Additional O
I certify thaC in the'performance of the work for�vhich this CI7Y � Tel No.. F
Fixed Appliances Not Over 1 HP . V
permit is issued,[shall not employ any person in any manner . PERMIT W
so as to become subject to Ihe Workers'Compensation Laws. Ra�ge_Heater D.W._ APPLICANT p.
. O�en _Dryer_W,M,_ � A�ORESS � �
Z
Date � Applicant Top _FAU _W.H._ � . . —
Hood_Fan ._Other_ CITY Tel No.
NOTICE TO APPL[CAN7:li,after making this Certifcate of Disp. _Room Air Cond__ LiCENSE oa
lixemption, you should become subjed to ihe Workers' � REG.NUMBER Gass-
Cnmpensatinn provisions of the LaAor Code,you must forth• power Apparatus&Large Appliances � DISTFICT NO. . PROCESSED eY
with comply with such provisions dr this permit shsll be _ � � � �
�deemed revoked. � . Size&Type HP,KW,KVA,or KVAR rn,/A� . ��
� � . UP to 1 incl. J•�/• .
FINAL
Over t to 10 Incl. ' DATE '
��—��'� VAUDATION�
.LICENSED CONTRACTORS OECLARATION - Over 10 to 50 Incl.- .�
1 hereM1y affirm ihat i am licrnsed under pmvisions of Ch�pter Over 50 to 100 Inc.- FINAL - ' �
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BV 1
ness and Professions.CoJe,and my license is in tull force and �
effect. ' Services � � - .
License Numbei Lia Class _ 0-200 Amp.Under 600 V � . . .
. 201-1000 Amp.Under 600 V .
Contractor Date � Over 1000 Amp.or Over 600 V - . ;'3�j�;A _
j� e 3 a
HOhtE O�tNER•BUILDER ISCCLARATIOY Temp.Power Pole&Appurtenances � ' '
- Sign with One Branch Cir�vit � - ' . � °••��C�^ -
I hereby affirm that I am exempt from �he ContractoPs qdditional Sign Braneh Circuits . �
License Law for the following reasan (Sectian 7071.5,Husi• - '�r Q(.�� �
ness and Professions Cnde): � � � �
� Misa Conduits&Conductoro � -
� 1, as owner of the property,will do lhe work and the Other(See Complete Fee Schedule)— - . �J�?�� -� �
stmcture is not intended or otfered for sale (Section . � . -
7044,Business and Professions Code). , .
CONSTRUCTfON LGNDiNG A(31iNCY. " � ' .
1 here6y affirm ihat [here is a construction lending aFency � � - - �
Cor the performance of the work for which Ihis Dermit is pERMIT FEE (5ub•Total) � �
issued(Sec.3097,Civ.C.). . � . �
Lender's Name . PLAN CHECKING PEE � (One-Fourth Permit Fee) - � � �
Lender's Addres: pERM1T ISSUING FEE $�L ` �
1 certify ihat I have read thit appiication and state ihet ihe TOTAL FEE. . pZ0 G � ' � � �
above in(ormation is torrect.!agree to comply with all Co�mty _ , - � .
ordinances and State laws regulating Elenrical wiring, and � • � � '
hereAy authorize representatives of this County to enter upon ' • - . � ' �
the abnve-mentioned property for inspection purposes. -SF.F.'RF.VF.RSF.�OR EXPLANATORY LANGUAGE �
�C�'�--�R) ��Dl��..C� i o�/-
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