HomeMy WebLinkAbout0785A WORKERS'COMPENSATIONDECLARATION 76Afi63 APPLtCATION F4R ELECTRICAL PERMIT �
CESD6G 12-80)
t hereby affirm that i have a certificate ot consent to se�t COUNTY OF LOS ANGELES BUILDING ANp SAPETY
insure,or a certificate of Wurkers'Compensation Insurance,or .
a certif' opy thereof(Sec.3800, • -C.j - .
�/�/^�(��"� ��(/��!/�1�99 FOR APPLICANT TO FILL IN �pg
���, —1'olicy o:'-• �^/Company ADDRESS
- � New Residential Bldgs.&Pools EACH NO. PEE
� Cert�ed copy is hereby Furnished. 1&2-Family,Sq.Ft. $ — $ LOCALfTY �
Multi•fami�y Sq.Ft. NEAREST
Certi£ed coDY t�filed with the nty 'Iding inspe� ion CROSS ST
de aztme Residential Swimming Pools OwnIER OR
/ FIRM NAME
Dat/ Applica Outlets:Rec._Light_Sw. � qDORESS
First 20
CER7IFICATE OF'EXEMPTION FROM W ERS' Total No. Additional CITY 7e1 No. �
WMPENSATION INSURANC
PLAN CHECK n-
(This secGon need not be completed if the work invOlveci �4PPl-ICANT V ;
by the permit is for one hundred dolters ($100) o� lessJ Lightinq Fixtures First 20 aooaess Q I
Additional
Total No. � Q
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY 7a1 No. - �
permit is issued,I shall not empby any person in anp manner PERMIT V I
so as to become subject to the ltiorkers'Compensation Laws. Range—Heater_O.W._ APPLICANT W I
Oven _Dryer_W.M._ ADDRESS� � Z 1
Date Appiicant Top _FAU _W.H._ — �
- � Hood_Fan _Other_ cirv 7e�No � � � i
NOTICE TO APPLICANi:If,af[er making this Certificate of Disp. _Room Air Cond._ LICENSE OR I
Exemption, you shwld become subject to the Workers' . REG.NUMBER lass
Compensation provisions of ihe Labar Cwle,you must forth- � Power�Apparatus&Large Appliances D�STR�CT NO. PROCESSEO
with comply with such provisions or this permit shall be � !\ � 3
deemed cevoked. - Size& ype HP,KW,KVA,or KVA �O , �. � ..T..... •
Up ta 1 Inci. �
FINAL - / �
Over 1 t0 70 InCI. OATE��� �-f
LICE:NSF.DCONTRACTORSDECLARATION OveriDto501nc1. X� 'fi� ��� VALIDATION i
FINA� i
I hereby afflrm[hat I am licensed under provisions of Chapter Over 50 to 100 Inc. B� i j"" �
9 (commencing with Section 7000)oC Divisiun 3 uf the Buxi� Over 100 ���%L�-�`�'{r't..�-..
ness and Professions Code,and my license is in fu(1 force and - �� I
effeet. Services �} � cn �j�� i
License Num6er `� Lic.Class � 0-200 Amp.Under 600 V `V� `�� ��'-7�D� � '6✓l
201-1 D00 Amp.Under 600 V
Contractor Pate /~ Over 1000 Amp.or Over 6Q0 V �
HOME OWNF.R-BUILDER DECLAItATION 7emR•Power Pole&Appurtenances I
I hereby eff¢m that 1 am ezemP� from the Contractor's Sign with One Branch Circuit �
License Law for[he follnwing reason (Section 703L5, Busi- Additional Sign Branch Circuits
ness and t'rofessions Code): . �
Misc.Conduits&Conductors �
� I, as owner of[he property,will do the work and ihe Other(See Comp{ete Fee Schedulel— G Q 7&5�
structure is not intended or offered for sale (Section
� 7044,Business and Professions Code). #�• • • • �2
CONSTRUCTfON LENDING AGHNCY
t hereby affirm that thero is a construction lending agency � • � � 2,� Q
for the performance of the work for wfiich this permit is pERM{T FEE (SuGTota11
issued(Sec.3097,Civ.C.). � •�• • � [,� Q�
Lender's Name PLAN CHECKING FEE (One•Fourth Permit Fee)
. 1 1.24�81
iender's Address PEAMIT ISSUING FEE
I certify thxt [ have read thix application and state that the TOTAL FEE `Q
above information is correct.I agree to cumD�Y with all County
ordinances and State laws regulating Electrical wiring, and �
hereby av orize re resentatives of this County to enter upon
the ab enti property for' spection purpa/sa. S6E'REVERSE fOR ERPLANA7'ORY LANGUAGE �
/I f /(
.... �..._....__....._..-"-'.'-_----`----""--..._---".'--.._.._...—'---....__.. _.._...._._._... .
Signatu Pcrcnit Date . ...----.'--'..'-'....._......_......-'.—"--'--.._.__......--'--."---'-�/
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