HomeMy WebLinkAbout1442A . WORKERS'COMPENSATION DECLARATION 76A663 �oiel APPLICATION FOR ElECTRICAL PERMiT � ','
1 here6y aftirm ihat I have a certifiwte of consent to seff �E-�'
insure,or a cert'rficate of Workers'Compensa�ion Insuronce, COUNTY OF LOS ANGELES BUIIDING AND SAFETY
or a certified copy thereof�Sec.3800,Lab.C.) �
P❑O��iCy NO. Compony FOR APPLICANT TO FlLL IN � 10B n / ��
Certified copy is hereby furnishad. New Residenlial Bldgs.&Pools EACF1 NO. �E ADDRESS �(I�� L�' � /} d` �
� 1 8 2-Fomil LOCALITY�
Certified copy is filed with ihe county buildi g i pec- Y•59�F�• $ — f Y
rion departmenr. Molti-family Sq.Fr. — NFARE57 Q ` _
� �� p/ Residentiol 5wimming Pools CROSS ST. /V
DateL_.E.L=d.1 Applimnl OWNEROR . - %
FIRM NAME E p V I Q t' -
CERTIFICATE OF EXEMPTIO F OM WORKERS' �i MAfL ':
COMPENSATION INSURANCE . Outle�s:Rec_light_Sw.__ �1 ;
ADDRE55 , /�1.�
ihis s�ctiun n�ed not bc com ktod IF fhe work invoivod 6 F��Sf� S � / I
( P y Foml No.� Addi�ional CIN Tel.No.
th�permit is for�n�hundrod dollors(S100}or loK.)
- 1 cenify Ihaf in the performonce of the work for which this APRICANiK
permil is issued,I shall not employ any person in ony manner (
so os to become subjeU�o the Workers'Compensation Laws. ��ghting fixtures Pirs�20 AODRESS
Total No. Additional
. QTY Tel.No.
pa�e ApplicoN Fiaed Applionces Not Over 1 HP PEftMiT � /� /
NOTICE TO APPLICANT: If, after making this Certificate ot pppL�CqM� }C JJ FJQQ.L ti�
�5 Examption, you shauld become subjecE b fhe Workers' Range_Heater_D.W._
� Compenwtian provisions of the Labor Code,you must forth- Oren _Dryer ..�W.M.T. ADDRESS�7 � �r S•s���} ��yC
with comply with such provisions or this permit shal4 be Top _FAU —W.H._- �� �
�deemed revnked. � . F{o� _Fan �Diher_ � CtTY ��{y��/� �(_ Tel.No?� 7 �
°EC llCENSED GOAIIRACiORSAEGIARAi.IAN. _.- ��CENSE OR - - �
�' I hereby affirm tMl(am ficensed under pravisions of Cfiaprer 9 Disp. _Room AK�Cond.�_-- � N��R y�� y��. � Ctass. C•i i
(mmmencing with Section 7000)of Division 3 of the Business pa„i,Br Apporatus&Large App�iances DISTRICT NO. OCES D BY } i
and Professions Code,and my license is in fu�l force and effect ;
�r Size 8 Type HP,KW,KVA,or KVAR 0 i
� License Number 3�v��� Lk.Class ��� � Up ro 1 Ind. FINAL v �
�` .g_�r Over 1 to 10 Incl. DATE .' O ��. .. VALIDATION �
Contractor�'�� r [RN�1-T��S Dole �-� Over 10 to 50 Incl. FINAL V �
� I am exempt under Sec. Over 50 fo I00 fnc BY �
B.BP,C.for this reason Over Ipp ��( y�
Services,Swbd.,-MCC 8 Ponefboards � Z
Date: 0-200 Amp.Under 600 V
Signoture 207-1000 Amp.Under 600 V xr� �w.'-F?
. ❑ Over 1000 Amp.or Over 600 V , �
Exemption for Reg.MainL Elect. +:° • • • •C
SING�E FAMIIY Temp.Power Pole 8 Appurtenances 1 � • 1 G��J
HOME OWNER-BUILDER DECLARATION Sign with One Bronch Circuit
1 hereby affirm ihai I am exempt from the Contractor's license • +�e � ;-.;)�:i.'�- .
� Low for�he following reason(Sedian 7031.5, Business ond Additionol Sign Branch Circuits
Professions Code): � '; i�-�{
. ❑ 1,os owner of Ihe propery,will do fhe work and ihe Misc.Conduits&Conductors
structure is not intended or offered for sale(Section Other(See Complete Fee Schedule)_ �
, 7044,Business and Professions Code).
� CONSTRUCTION LENDING AGENCY � G � ,
I hereby offirm Ihat there is a construction(ending agency for �7 �
, the performonce of the work for which ihis permit is issued PERMfT fEE � -�� ----�{Setb-Fo1at)- �����-���- .1,J ......... . , . �
(Sec.3097,Civ.C.). � . . . -._ . .. . . . I
� �� � � � � PLAN GkIECI�ING FEE . '��
Lender's Npme
. PERMIT ISSUING FEE - O� � - � � . - . . „
- lender's Address . . ... . -. --............ .. . . . .. . � . - . .
� 70TAt FEE ... ........ ... .n ..0�-- - - � .� . .. _.
I tertify that I hove read�his application and stote that�he �e, . .
above information is correcL I agree to wmply with all County - - . .. . . . . . .. . .. . ... . . .. . ...
ordinances and Stat ws re9ulating Elecfrical wiring,and . . .... .. ' �� . . .. .. . . -.. -. � . .- . � . . . . . . . . .
__ . .... . . . .... ....
hereby authorize r re� nlatives of this Couny lo enter upon � � - . . , � - -- ����� ������
�he ve enti ned ropeny for tnspaction purposes. SEE REVERSE FOR EXPIANA70RY LANGUAGE
/-29�1t� �
� ignotur'of Dermittee Da�e
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