HomeMy WebLinkAbout0558A WORKERS'COMPENSATION DECLARATION 76A663 10/ei APPtfCATION �O� ELECT�ICAL PEP.MIT �
i herehy offirm that I have o certificate of consent b self CE�06G
insure,or a certifitate of Workers'Campensation Insurance, COUNTY OF LOS ANGELES BUIIDING AND SAFETY
or a certified copy ihereof(Sec.3800,Lab.C.)
P�olfcy No. Company FOR AMLICANT TO F{ll IN ��B
Certified copy is hereby furnished. New Residential Bldgs.8 Pools EACH ND. FEE �ORESS o9 A
Q � I R 2-Famil 5 Ft. s — S IOCALITY �
Certified copy ia fiied with fhe cou ry b ilding insper 1'• 4�
. tion departmenL Mvlti-fomily Sq.Ft. CROSS 57.
Residential Swimming Pools OWNEROR
Date�I���'�SAPPIimnt - . . .
FIRM NAME
. CERTIFICATE OF fXEMPTION FR WORKERS' Outlets:Rec�Light_Sw._
C�MPENSATION�NSURANCE DDIRESS 1 �Vfl
This sxibn nood nof bo com Io1od if fh�work inwlr.d 6 First 20 g
� P y Total No.�� Additional CITY Tel.
the parmil is for ono hundrod dollan(5100)or leas.)
!certi4y Ihol in the performance o4 fhe work lor which Ihis 7lAN CHECK
� PVLICANT
permft is issued,I shall not empfoq any person in any manner
so as to become su6ject to the Workers'Compensation laws. l�9hting Fiztures First 20 • ADDRE55 �
-- Fotal No._� p`dditional CITY Tel.No.
pale App�icant Fixed Applionces Not Over 1 HP pE��7
-NOTICE TO APPlICANT: ff, after making this Cerritiwre of AP%IG4NT
Exemption, you should become su6ject to ihe Workers' Range,Heater_O.W._
Compenwfion provisions af the Labor Code,you must forth- Oven _Dryer _W.M.— ADDRESS �za
winc �omply wifh such provisions or ihis permit shall be Top _FAU —W.H.—.-
deemed revoked. Hood —fan _Ofher— CITY Te4.
LICENSED CONTRACTORS�ECLARATION uCENSE 4
1 hereby ofEirm ihat!am licensed under provisions�of Chapter 9 Disp. _Raom Air Cond. __ REG.NUMBER Z. C�Ou'D` }
�rommancing with Section 7000}of Division 3 of the Business DISTRICT NO. PR BY a �
and Rofessions Code,and my licrose is in full fwce and effect Power Apparatua&Lar9e Appliances /� � i
� � l{ Size 8 Type HP,KW,KVA,or KVAR P•�
License Num6er���Z'� Lic.Ctass� FINAL �
� Up to 1�ncl. DATE �
��, � Over 1 to 10 Ind. �1��� VALIDATION ~
Contractor J`,� AG�• �ate�f��/y'9 3 Over 10 to 50 Incl. W �
� FINAL p_ 3
1 om eaempt veder$ec. Over 50 to 100 Inc BY � #
B.BP.C.for thia reason �g��� � �
Servites,Sw6d.,MCC 8 Panelbaards � ;
Date: 0-200 Amp.Under 600 V �
Signature 201-1000 Amp.Under 600 Y � . .. _. ,-„ �. �
❑ Over lOW Amp.or Over 600 V -�-''��"f'
Exemption for Reg.Maint.Elac1. ��; �
SINGLE FAMILY +� � • • �
Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILOER DECIARATION Sign with One Branch Circ�i� � • " �t>'.���'
1 hereby affirm thot i am exempt from the CoNroctor's License qdditional Sign Branch Circoits - —
�aw for the following reason(Section 7031.5, Business and • . .,.., �
Professions Coda):
❑ i,as owner of the ro i II do ihe work ond fhe Miu.Conduits 8 Conductors j j, i a—�;�,
P ��Y'W� Other See Cam lefe Fee Sthedole
:tructure is not intended or offered for soie �Section � P �— �
7Q44,Business and Professions Code}.
CONSTRUCTION LENDING AGENCY
I hereby affirm thai ihere is a construction lending ogency for
�he performonce of the work for which this permi�is issued pERMIT FEE (Sub-Tatal)
(Sec 3097,Civ.C.).
, PIAN CHECKING FEE
Lende�'s Name
PERMIT ISSUING FEE
Lcnder's Address
I certify ihat I have reod�his applicotion and s�ate that tha TOTAI FEE
obove informalion i torrect.I agree to comply with all County
ordinances ond 51 te lows regulating Electrical wiring,ond
hereby aoth e r resentaiives of this County to eMer upon �
the -m nrion d properry fa.�nspection purposes. SEE REYERSE POR EXPIANATORY LAPIGUAGE
� J!—I�BS {
Signalore o Permi tae Date !
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