HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECLARATION 76A663 +oi8+ qppLICATION FOR ELECTRICAL PERMIT - {�
� I here6y aflirm that I have a certificate of consent to self insure, ce-eosG
or a ceAificale ot PJorkers'Compensation�nsurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY . Ll
. copy theAreo�f-(Spec.3p800.Lab.C.)
PolicyFJ,ti�1�O,O�G3Comparry��h������Al U� FORAPPLICANTTOFlLLIN ODRESS�ab C�VV��y �O S K- M�
❑ Certilied copy is hcreby fum�shed. ... New Resipential Bldqs.&�o�ls �q EACH NO. � FEE ,_
� � 1 8 2-Family,Sq.Ft..,d,.LS-� S O — � LOCALITY ��j��-V � �
Certified copY is fletl with the county building inspection
depar[m=nt . � MNtI•femily Sq.Ft. — NEMEST
Date � � Residential Swimming pools ow EH oH ,
Applicant
FlRM W161E �A
�CEF7TIFICATE OF EXEMPTION FROM WORKERS' � putlets:Rec_L'ght_Sw.— - � ' '. � ', MA�� • !/
�� COMPENSATION INSURANCE � '� ' �� '�nooaess3�sr i�lU� G.,
(This sectbn need not be compleled if the wwk involved by the Firsl 20
permit Is tor one hundred dollars(5100)w less.) Total No. Additional CITY`C.�5�� � .No.$�—I(b
I Geltily th3�irl thC pPftarfnen�@ Ot fhC vrofk fOf WhiCh�hi5 OMmiI " .. ' APPLICANT K
is issued,I shall not employ,rry person in aity mnnner so as to -
— become subject to Ihe Workers'Compensation Lavrs. L'ghti�Fixlures First 20 A�DRESS �
� ' � � � - � '� Tolal No. Additional CITY - Tel.No.
Daie Applicant Flxed Appliances Not Over 1 HP
NOTICE TO APPLICANT: It, after making this Certifitate of PEHMIT ' _
Exemptbn,yrou should become subject to the Workers Compensatan Rarx�e_Heater_ D.W. _ nra�icnNi C CL �C�'2\C
pmvisions of the�bor Code,you must forthwith comply with such Oven—Dryer_ W.M._ ADDRESS ,Q� �
provisions or ihis permlt shall be tleemetl revoked. Top _FAU _ W.H._ �� � CITV�� I N O C��0 - Te�.r�o.�'�J—(��f6�
UCENSED CONTRACTORS DEGLARATtON Hood_Fan _ Other_
I hereby aflirm th,t I�m iicensed untler provisions of Chapter 9 uce��sE on 1/ p p.
, (commencinq with Section 7000)ol Division 3 of the Bu5inC55 and Disp.�—Room Air Cond. _ - REG.NUMeER �`I 1 O O p 3 ��azg� ���(}
%ote55i0n5 COdC,��d my license iS in full fOr�@ and e(fecL Pow2f App3fetuS 8 L�rge Appli�nCBs . DISTF7ICT NO. PftOCESSED BY
/�p p, I� Size&Type HP,KW,KVA,or KVAR f ' �C���.,�p �Q
License Number 7 1��O 3 Lic.Class `��d �- Up to 1 Incl. - FlNAL �+
�f�C�`R ICRL y�,Q9 Over t to t0lncl. DATE l�f �� �
Contractor Dzte <<� VALIDATON � .
� ����— Ovcr 10 to 50 Incl. FINAL V
� ❑ I am exempt under Sec. - Over 50 to 1001na . gy � ' . . . .. W
8.&P.C.for this reason Over 700 �
Services,Sw6d.,MCC 8 Panciboards � � � "�� " �� Z
- ' Oate: 0-200 Amp.UMer G00 V �=I � Y.I f i
Signature 201-1000 Amp.Under 600 V - - � -
��❑ - - � � � Over 1000 Amp.or Over 600 V �-'o • • a x�
Exemplbn For Reg.Maint.El=ct.
I - 1 26[s6
S!NGLE FAA!!LY - � Temp.Power Po!a 8 Appurtenar�ces , , . .
HOME OtiNNER-BUIL�ER DECLARATION Sign with One Br2nch Circuil ^ � I C c,�:v;:;
I hereby affirm that I am exempt from fhe Contractor's License Law '
for the lonowirx�reason�Ser.tinn 7031.5,Rus��ess and Pm!=ssions Additanal S�gn Branch Circuits -
coeel: 0 A�b—;;•�
❑ I,as owner of the property,will do ihe work znd the structure Misa Conduits&Conductors � - -
is not intended or offcrctl for sale(Sedion 7044,Busir�ess 01her(See Complele Fee Schedule)_ , _
. and Prefessions Code).
CONSTRUCTION LENDING AGENCY -' - ,
I here6y affirm that ihere is a construMion lending agency tor the �
perlormance of the work lor which lhis permit is issued(Sec.3097, pERMfT FEE � � �� I�b-Total) �� � � � �
Civ.C.).
- PLAN CHECKING FEE - - - � � -
Lender's Name pERM1T ISSUING FEE . . � �O SD
Lender'S Address
I certiFy th21 I havo read ihis applicafion and state ihat the above TOTAL FEE . (��jr ,L/ . .
information Is corract.1 agree to comp�y with all County ordinances
and Sta!o laws regulatirg Electrical wirine�,and here6y authonze . . .
representalives of this County to enter upon Ihe above-mentioned � ��
propert fW inspection�wrposes. -
� - SEE REVERSE FOR EXPLANATORY LANGUAGE -
C 2 �`
Sic�nature ot Permdtee D te
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