HomeMy WebLinkAbout1442A � WORKERS'COMNENSATIOR DECLARA7ION 76A663 APPUCATION FOR ELECTRICAL�PERMIT . ,r�
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`I hereby atfirm that 1 have a certi[icace ot consent to se�t COUNTY OF LOS ANGELES BUILDING ANO SAFETY L1
insure,or a certiticate of Workers'Compensetion Insurance,or � � ,
a certified copy thereof(Sec.3800,Lab.C.)
� . FOR APPUCANT TO FILL IN JOB
i� Policy No. Company ADDRE �
� New Residential Bldgs.&Pools � EncH No. FEE ��
❑ Certified eopy is hereby furnished. . 1&2•Family,Sq.Ft. $ — � �� � � �j
Multi•family Sq.FL — N A
� Certified copy te filed with the county building inspection Residential Swimming Pools CROSS ST .
� deDariment. � � OWNER OR
� tl� „� FIRM NAME �
Date ApPlicant Outlets:Rec.�Liqht_Sw.IG MAIL !TE
Firs[20 •�'v 20 �V qDDRESS z •�'� •
CtiRTIPICATE OF LXEM11P710N PRO�f N'ORKERS'- 7otai No.��L— Additianal "�� � �`� C CITY� Z�TeI Na.'T� -(� }
COMPENSATION INSURANCE
. � � � PLAN CHECK a
' APPL�CANT 0
(This section nced not be completed if the work involved ` ,rv v ,�
Light�ng Fixtures First 20 ADDRE55
6y the permit is for one hundred dollars (SI00) or Icss.) /-�� Addltional� � �
�. I certity that in the pertormance of the work for which this Fiued Applianae N t Over 1 HP CITV Tel No. U
permit is issued,I shall no[emD�oy any person�n any manner PERMIT W•
� so as to become subject to Ihe Wbrkers'Compensation La���s. Range_,Heater_D.W._ APPLICANT d
- Oven _Dryer_W.M._ \ ADDRESS Z
� Date Applicant ' � Top _PAU —W.H._ CITY Te1 No.
� � � Hood_Fan _Other_ �
NOTICE TO AYPLICANT:If,after making this Certificate of pisp. _Room Air Cond� h�C uCENSE OR
Exemption, you should become�su6ject to the N'orkers' REG.NUMBER Ciass
Compensotion provisions of the Labor Code,you must furth- pOwe�Apparatus&La�ge APp�iances �IS7RICT NO. PqOCESSED BY
� with comply with such provisions or this permif shall be Size&Type HP,KW,KVA,or KVAR
deemed revoked. � Up to 1 Incl.� ` �°�, Jn �
� OVer 1 to 101nCL C�.C� /p �, ��FINAL � �
LICENStiD CONTRACTORS DECLARATION � S,�� DATE VALI�ATION
Over 10 to 50 IncL .
, 1 hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc.� '����� BY P'L
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 ����� � �
' ness and Yrofessions.Code,�and my license is in full force and . .
effecL � Services
� � 0-200 Amp.Under 600 V ��d — �1.4 Q 2,A
� License Number Lic.Class �
201•1000Amp.Under600V �ie•.Cf� �, (pOt'c
� Coniractor Date Over 1000 Amp.or Over 600 V ^�'���� — . . � #�� � � �'9
FfOME ON'NER•BUILDER DECLARATION O U — d ,Ci J-� `�.• � 2 Z 2'O
Temp.Power Pole&Appurtenances D �L .
I hereby �lfirm that I am exemp[ from the Contractor's Sign with One Branch C�r[uit �i'�7 I • • � 2 7,2 Q c�i
Additional Sign Branch Circuits v
� License La}v for ihe following reason (Section 70�1.5, s�s�- . 1�� 3 � �G 2 0 3—8 2 -
ness and Professions Code): � ;/� �
� Misa Conduits&Cnnductors
� � I,as o�vner ot the proDerty,will do the work and the Other(See Complete Fee Schedulel-- � , �
. . structure is not intended or offered for sale (Section
7044,Business and Professions Code). 7 -r — �
� CONSiRUCT10N LtiNDINC A(7ENCY '
I'hereby affirm that therc is a consiruction lending agency � �
� tor the performance of ihe work for which this permit is pERMIT FEE (Sub-Totall �� Op �
� 'ssued(Sec.3097,Civ.CJ, n�
� Lender's Namr PLAN CHECKING FEE (A �aa�Gw�Y�Permit Fee) � 7 20� �
Lender's Address PERMIT ISSUING FEE �
I ceNify that I have�iead this appfication and state tbaf Ihe TOTAL FEE
above intormation is correct.1 agree to comD�Y wi�h aii Coimty - .
ordinances and State laH�s regulating Elec[rical wirin6� and �
hereby authorize representatives of this County to enter upon �
�. the above-mentioned property for inspection purposes. . � SLE'RGVERS[FOR ERPLANATORY LANGUACE � �
Signature of Permittee Date � -
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I I�n_L:;;��.�1.,:�Ibcl I nm c�crtp[Irnm ILrContractnr'a
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