HomeMy WebLinkAbout1351A � WORKERS'COMPF.NSATIONDECLAAA710N 76A663 APPLI�ATION FOR ELECTRICAL PERMIT _ �
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� t hereby erfirm that I have a certificate oe conaent to setf COUNTY OF LUS ANGELES BUILDING AND SAPETY
I insure,or a certificate of Workers'Compensation Insurance,or �
n certified cnpy thereoY(Sec.�3800,Lsb.C.) /�� �
I wAA2+7. � /j�J� /YA FOR APPLICANT TO Ft�L iN � Jpg ^/O�!
� Policy No.f��LComp2ny ��� f�'�� ADDRESS d� �a
� . New Residential 81dgs.&Pools EACM NO. FEE
� � Cerfified copy is here6y furnishe4. i&2-Family,Sq.Ft. $ -' s LOCALIT
� �ertified co u fikd wit the count huildin Mutti-family Sq.Ft. CROSS ST � �
py' (� y g inspection �R���niiat Swimming Pools
� department. � . OIRM NA E t � I
` Date�/ � App� t� F��`�L`�,��L.1f1 1(�utle[s:Rec��Li9ht_Sw._ rf ADDRESS(3 C-l7FYVtvt-�- 7�
J i t� v I flilr 11'yT First 20
! CERTIPICAiE OF&XEhiP710N rROM WORKERS' Total No._.�� Additional dTV � 7e1 No.
� COMPENSATION INSURANCE � Ya
PLAN CHECK
(Thia section need net:be sompleted..if tl�e WOi1C.iilvOlved_: APPUCANT V
� • � LigMing Fixfu`2s �First20..... .:. . . .. . . ._ . :. ADDPE55 -
} by._!he permit_�s for_one_hundn-d doilacs (SI00)oe less.) qd itia. -"
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� 1 certiPy<hat in the perfarmance nf the work tor wh�ch this CIT�V- .._:Tei Na. �
� . Fixed Appliances Not Over t HP .... � . .. . . h-
permit is tssued,i shall nof employ any persnn in any manne7 PERMt '� i f�.-' -��` 3 {�fi U
so as�to brcome subjec#to tkw Workers'Compensation La�vs. Range_Heater D.W._ -, APPLIC�PY'1`� � - `���� '•"��• W
Oven _Dryer_W.M._ A�6R�sS " `� �r��s ��`, z
� 7oP _FAU _W.H.._ — ; ::, `�SI�tFJTA ANr1 f: �
Date Applicant CITV Ta�No.�b-3 i 3
Hood_Fan _Other�
� NOT7CF.TO APPLICANT:If,after making this Certificute of Ois . Room ir C nd,_ LICENSE OR ag3�2 Class ��U
Cxemption, you shoutd become sub]ect to the Workers' REG.NUMBER 7
Compensation provixions of the Lab�x Code,yov must furth- pow r � eratus&l.arge Appliances DISTRICT NO. P CE ED BY
with comply with such provisions nr this permit shall he , � /�
deemed revoked. Size&Type HP,KW,KVA,or KVAR �/
Up to i Inol. `� �
FINAL
Ov2r 1 to 1 O Incl. �ATE ��f' VALIDATION
LICENSEU CONTRACTORS DECLARATION O �
Over 10 to 50 Inc�.
I hereby affirm that[am�icensed under pmvisions of CAepter Qver 50 to 100�nc. � FINAL
BY
F 9 (cnmmencing with Section 7000)oT Division 3 of the Rusi- Over 100
4 rtess and Professians Code,end my ticense is in full force and
� effect. Serviees
, License Number� � Lia Class �—`� 0-200 AmP•�lnder 60Q V
{ ` 201-1000 Amp.Unde�600 V
��iMr�c�i tiZ� }�i�(:i�il.A�b�(,�_'��3d�/ O�er 7000 Amp.or Over 600 V c..�1 ti'�,.�i 1 f�,
� HOME OWNER-BUILUER DECLARA7'10N Temp.Power Paie&Appurtenances ;?•• . + •
Sign with One Branch Circuit � ' ' .
1 hereby afCvm fhat I am exempt (rom the ContractoPs � . � �y� p z,�1
License i.aw for the following rexson (Section 7031.5.Busi- Additional Sign Branch Circuits -
ness and Profetsions Code): � � e,-� r,_' ��,�,
� Misc.Conduits&Conductors . . .
� I, as owner of the property,will do the work and the Other(See Compiete Fee Schedulel— y� '� i�...�("�
structure is not intended ar offered for sale (Seqion
7044,Business and Professions Code).
CONSTRUCTION LBNDING A(3ENCY
I hereAy affirm lhat there is a constructiun lending agency
for the performance uf the work for which this permit is pERMIT FEE ISu6-Total} O
issued(Sec.3097,Civ.C.): �
LendeYs M1tame pLAN CHECKING FEE (O�e-Fourth Permit Fee� '
Lender's Address PERMIT ISSUING FEE
�
I cettify Ihat [have read this aFplication and atate that tpe TOTAL FEE '
above informetion is correct.I agree ro comply with all County �
�rdinances end State taws regulafing F.lectrica] wiring, and � /(� d .
hereby authorixe representatives of this County to enter upon r
the xbov mentioned Dr �ty for inspection purposes. � SEE'R�VfiRSE FOR EXPLANATORY LANGUAGE
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ISignature of Permittee Date . .
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