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HomeMy WebLinkAbout1163A (5) WORKERS'COMP�NSATIONDECLARATION �6A663 - APPLICATlON FOR ELECTRICAL PERMIT � . CE$06G 1�-801 i hereby affirro that I have a certitiwte of consent to self COUNTY OF LOS ANGELES BUILDWG AND SAFETY insure,or a certircate of Workets'Compensation Insurance,nr � � a certified copy thereoP(Sec.3800,Lab.C.) � FOR APPLICANT TO FILL IN ��8 z 10 3 5 COO� S r i n s D r. � Pollcy No pany aooaEss . P 9 ��jF�� i U 111 5 5 O C New R¢9idential Bldgs..&Pools EACH NO. FEE � Certified copy.is hereby furnished. 1&2-Family,Sq.Ft. S — $ LpCALITY . Multi-family Sq.Ft. ARE T � Certified copy is fi 7ed with e cpu y"6uilding inspect�on ` CRO55 ST department. J �,I Residentiat Swimming Pools OWNEH OR I IRM NAME D r. Aq u i �8 Date Applicant Outlets:Rec.�Light_Sw._ `D r ��M� �� Same � First 20 A RESS CtiRTIFICATE OF EXEMPTION FROM WORKERS' Total No. Add�tional CITY p,t;, . Te�No.595-343o � COMPENSATION INSURANCE PLAN CHECK a CI'his section need not be completed if the work involved ��9nting Fixtures First 20 A`PPL�CANT V by the permit is for one hundred doltars ($100)or less.) aooREss Total No. Additional C I ceRify that in the pezformance uf the wurk for which this CtTY Tel No. � � Fixed Appliances Not Over 1 HP permit is issued,1 shali not employ any person in any manner PERMIT V so as to become subjeci to the Workers'Compensation Laws. Range_Heater_D.W. aPP ICANT T�10lI1a5 G roup a Oven _DrVer_W.M._ nooAEss i 2900 GG B 1 vd. y ❑ate Applicant Top _FAU _W.H.,,,_ Z Hood—Fan _Other_ CITY Tel No. NOTICE 7U APPLiCANT:If,afcer making thu Certificafe of Disp. _Room Air Cond._ L CENSE O ' Ezemption, you should Gecome subject to the Workers' REG.NUMBER 3>5542 ���s 4 Compensation prnvixions of the Labor Code,yov�must forth- power Apparatus&Large Appliances �ISTRICT NO. PHOCESSED Bv with compiy with such provisions or this permit shall 6e Siie&Type HP,KW,KVA,or KVAR � Q �� deemed revokeJ. � �_ UPto}Incl. �•�� � . NAL Over 7 to iQ Inci. LICENStiD CONTRACTORS DE:CLARATION Over 10 ta 50 Incf. DATE f;�t�i✓`_ VAUDATION r� I bereby atfirm that F am licensed under provisions o(Chapter Over 50 to 100 Inc. FINAL . 9 (commeneing with Seetion.7000)of Division 3 ot the Busi- Over 700 BY ��;'�-�,2�,�,�..{__ ness and Rofessions Code,and my license is in full force anJ effect. $ervices � ; Licertse Num�S 5 5 42 Lic.Ctass S C 4 4 4200 Amp.Under 600 V � Thomas Grou� 204-t000Amp.Under6pQV Contractor D te Over 1000 Amp.or pver 600 V HOME OWNER-BULLOLR DECLARATION Temp_Power Pole&ApPurteqe�+ces 1 hereby affirm that [ a m exempt from the Contractor's S�gn with One BranCh Circuit License Lnw for the following reason (Section 703L5,Busi- �ditionat S�Bn BfanCh CirCUi[5 �1 1 6 3 A ness and Prufessinns Cude): - Misc.Conduits&Conductors #••���2 � I, as owner ot the property,wiil do the work and the ptner(See Complete Fee Schedulel� � structure is not intended or offered fur sale (Section �) •��z,�Q 7044,Busineas anJ Professions Code). � CONSTRUCTION LENUING AGENCY •���� 'L j O� I hereby affirm that there is a construction lending agency . fm the perfurmance of the work for which this permit is pERMIT FEE (Sub-Total� „ � - r 2 3 O�$}� issued(Sec.3097,Civ.C.). . 3 Lender's Name p�qN CHECKING FEE (One-Fourth Permit Feel as o. Lender's Address PERMIT ISSUING FEE �f � � 1 certify that I have read this application and state that the TOTAL FEE � 2 �0 above infurmation is correct.I agree to comply with all Coimty , ordinances and State laws regul'ating Electrical wiring, and � � hereby authori2e representa tives nf this County to enter upan the� ve- i'oned proper�ty for inapection purposes. SEE'RPVERSE FOR tiXPLANATORY LANGOAGE F . ��/'�� - S gnature of Permittee j Dale - . � . � � "� v'y 4 o A V,i� G�'' ��,~.y`y R v�, s ��`'� y t.� ; .�"_"i'..� y ` . • S_ W `. �y .C � V T _ � "' � . �n "-�^> u �. ay.j i. �. tt O � _ r -. ^.� ca ` ��\ �y ^ y p'.+- p, 'a a. C � ,� u .. c`S ��' o Y ,. . . M'Q �� l'��y G. ^ W �� � � ' _ �'� ��, � �C c+ � � a- —" � � ._r � � O a���� _ � ' s �,,.�.'- p� o c _ ,,.., 'r' _�" n .: i� - , ✓ .. ' x, ba J c� �, �.. v. _ � � '�1 �i ` � �'� � .� ''�p�%:�� .., i•r` � C,,-'r..w�' ti.� � c. G ` 1 O U�V "'� CS «.~ '4" �%`` �.-•. ••� - V h w+w, �'� �"• n .�� 1 � :•� c.:'V `=L �, C: 'v v� . � v. 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