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
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