HomeMy WebLinkAbout1290A (6) _ �
WORKERS'COMCENSATION DECLARATION 7oA663 �o�e, qppL1CAT10N F�R ELECTRICAL PERAIIIT �
I hereby a(Firm[hat 1 hsve a certificate of Consent to self insure, CE-BosG
' or a certificate of Workers'compensation msurance,or a certisied CQUNTY OF LOS ANGELES BUILDING AND SAFETY
copy theieof(Sec.3800.Lah C.)
Policy No. � - � - Fpmparry iOR APPLICAHi'TD F1LL IN � .106 � .'C
_�, Certified copy is he�ebY,fumished.,. . . New Res�ential 61dgs.8 Pods FACH NO. FEE ADIXiEss �� 5,� (,(]/�D '� K.
� _ Certlfied copy is hied wMh the�courty bulldirq inspecfbn 1 8 2-Family,Sq.Ft. _ $ = $ LOCALITY.
NEAAEST. J
. -�.eepa�tment....�. ,- �_ .-- -- .-...� . .. . Muki-famnysq.vt. cRosssr. t g S I �RB
Date qpplicant Resideniial Swimming Pools � � �� '�- � q.yNEq oq � �
. ... _ �I G ROS
- --. ....._. ,,. FIRM NAME
.... ........
._ CERiIFlCATE OF EXEMpTION FRpM VVORKERS'�� � Outlets:Rec�light�SW.� ' MAIL 3._�. �j a�„,��
. -- .-�CONI�EN3RFtDhF�iH,,..�.,,,.._.�..—_.__.__._.. . _. ADDRESS l7 YFY
(This section��need noT be eompkted li the wwk drnolred by t�e . . ... . ..First 20°. -_-. . � . p,�r
.permit is/or one huadretl tlollars 15100)a less.) - Total No. � AOtlttfonaF���� �� � �-��- -���� � �� �. �m � Ta�'N0'� �a J�3
1 cetti!y that ir1 the peAOrmanC@ OF the work for which this permii . PLAN C�ECif- � -��
is issued,I shall rwt employ arry person in arry manner so as to ��A� �
become subjec[b the Workers'Gompen tion Laws. Lighting Fixtures Flrsf 20 ��R�ORE$S - -�� �
Additional
Total No. � ��- � GTY ��^�� Tel.No. r��
�1ate�_AGPlicant Fixed Appliances No[Over i HP p�pp�R
NOTICE��TO APPLIGANR-7F,�a � making.this Certificate of ����
Ezemption,you Shou�tl become su, b the Workers'Compensation Range_ Heater_ D.W. _ ��-�C�NT
provisions of the Lator Code,you must iorihwith canply wil6 such aven_ Dryer_ W.M._ ADDFiESS
-provisions or this permit shall be deemed rEwked. Top _ FAU � W.H._ �
CRY '�E Tel.No.
LICENSED CONTRACTORS DECLARATION Hood—Fan _Other_
I hereby affirm that I nm licensed urder.pmvisions ot Chapter B DisR — Room Air Cond. _ uCENSE oR ��
(commencing with Seciion T000)of Division 3 ot the Buaness and REc.NUMeER
Prdessions C.ode,and my license is in fuil force and effect. power Apparatus 8 Larc,�e Appliances DISiRiGi NO. PROCESSEo BY
Size&Type HP,KW,KVA,or KVAR '� �
License Number Lic.Class �p to i Incl. � FINAL,��� �f
Over i ro 701nc1. DATE �� �.. ypLIDATION �
Contractor � Date Over 10 to 50 Incl. �
❑ fINAI ._.....
1 2m exempt Undef SeC. Over 50 to 7001nc. gy �
� B.BP.C.for t^.is reasnn Ove�100 Z
Services,Swhtl.,MCC&Panelboards �
Date: 0-200 Amp.Under 600 V
� Signature " 201-7000 Amp.Under 600 V
� ❑ Over 1000 Amp.or Over 800 V
Exemp[ion for Re9.Maint.Elect.
` HOME OWNER-BUEL.DER DECLARATION Temp.Power Pole 8 Appurtenances _�1 G Q,O q
I Sign with One Branch Circuit .
• I hereby affirm that I am azempt fmm ihe Contractor's License Law
� for the following reason(Seciion 703L5,Business antl Professions ��tional Sgn Branch Circuits � 3 ' � �I S
� codel: , � ^ -��x
� • + �.:uca
Misa ConduRs 8 Conductors
X t,as owr�'of the property,will tlo the work and the sVucture ����—8'�
� is not intended or offered ior sale(Sedion 7044,Bi�siness Other{$ee Complete Fee Schedule}_ �
and Professions Codel.
j CONSTqUCT10N LENDING AGENCY
{ I he2by atfirm that there is a cons�ruction lercling agency for the
� performance of the work for which this permtt is issued(Sec.3097, pERM1T FEE (Su�Totaq
� Civ.C.�.
PLAN CHECKING FEE -
� Lender's Name
PERMIT ISSUING FEE /O
� Lender's Address / �
I certify that I have read this epplication and state that the above TOTAL FEE
� information is correct.I agree to comply with all County oidinances
and State laws regulating Electrical winng,and hereby euthorize
' representatives of thls County to enter�pon the above-mentioned
proper for inspectian purposes. .
� p SEE REVERSE FOH El(PLANIiTORV LANGUAGE
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