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HomeMy WebLinkAbout1382A NJORKERS'COMPENSATIONbECLARAT10�1 7FA663 i0�8� � - � - � "-����� � - -� , � � �hereby aY:irm that i have a ce::ificafe o!consent to se!f insure, cE-ao°G APPLICATION FOR ELECTRICAL f�ERIVIIT� {j� or a cerificate o'l"Jorkers'Comp=nsatien Insuranoe.or a certified COUNTY OF LOS ANGELES BUILD��NG AND SAFETY LJ copy ihereof(Sec�380QLa6.C.i PoliCY ND.-1 � COmpany ' . . FOR APPUCANT TO FILL IN J06 . . ... ... . ._ ..... ... ...... . ❑ Cer,ified copy is hereby fmnished. Nev��Residentia�Bldgs.&Pools EACH NO. FEE AooaEs� '����� �� � Certifie.^, Copy is filed wilh the county 6uilding inspectien 1&2-Family,Sq.Ft. $ — $ LOCALITY �u� � , �' -�. denartment. Multi-family Sq.Ft. — NEAREST � Residentizl Swimming Pools caOSs Sr Date � Appl'icanc� -� � . OUVNea�a L ' FIRAA NAME CERTIFICATE OF EXEMP716N FROM N10RKERS' putlets:Rec—�i�ht—Sv�.— ��� y � - - COMPENSATION WS�RANCE AODReaS J �,- (7his seciion need not be�completed�if t}ie work in4olved 6y the First 20 permit is for one hundred tlollars($100)or less.)�� � To;al No. Acditionai CITY Tel.No. �}. �� PLAN CHECK ' - - I certif�that in the pc-rformance of tne work for-which this permi; ,4PPLICAN7 j �lj �Q_ is issu2d.I sh�il no,employ any person in any manner so 2s to i become subject to the Workers Compensa!ion Laws., Li�htin5 Fixtures First 20 ADDFESS '�� �o a.0 n Q�1fQ�y To[al No. Additional Cate�Applicant� � ' al . CITY � Tel.No. � � NOTICE� b FPPLICANT: li; af«er making this •er ificate of Fixed Appliances No!Over 1 HP peRMiT � Exemption,you shou!d become suGjBCt t0 the Workels mpensa n Ran9e_ Heater_ D.W. _ APPLICAUT }��. provisions of the LaCor Code,you�must forthwith comply vuith uch Oven _ Dryer_ W M._ I ADDRESS provisions or thls permit sha'I be deemed revoketl. Top — FAU _ W H._ LICENSE�CON'RACTORS DECLARATION � CITV Tel.No. Hooa— F2n _ Other_ I hereby affirm that I am licensed uilder provisions of Chapter 9 � ��GENSE OR Disp. — Room Air Gond. REC NUPABER (commencing�vith Sectfon 70001 of DivisiCn 3 of the Business and — '� 'g Class. � Professions Code.and my license is idfull force and'effect� power Apparatus&Large Appliances �ISTRICT NO. PROCESSEO BY �y Size 8 Typs HP,KW.KVA,or KVAR � -O License Number�J`���J Lic.Clzss ��1 Up to I Incl. � FINHL . .r U Over 1 to 101nc1. i DATE ��^�t ` y�� VALIDATION 0 Gonhactor ��� "��a�7�te� 6 ❑ Over t0 to 50 Incl. FINAL n.. --1 �"' I am exempt under Sec. Over SC to 100 Inc. BY �" �— � B.&P.C.`or this reason Over 100 � d . � Services.Sv�bd.,MCC 8 Panelhoards , � Da}e: 0-200 Amp.Under 600 V : . ��S.7 P Z Signa[ure _ 201-10�00 Amp.lJnder 600 V „ , K e a[ � - " - ' Over 1000 Amp.or Over 600 V * Exemption for Re£.Maine.Elect. f � %�.5�1 �� SINGLE FAMILY � � Temp.Power Pe�e&ApCur[enances HOME OWNER-BUILDER DECLARATION " " -'"•`�%:i<: I hereoy affirm that I am exempt from the Conhactor'S License Law �ign wiih One Branch Circuit for the following re25on(Section 7031.5,Business and Protessions Adcitiona Sign Branch Circuits i���^(�._�'� Codei: ❑ ����dt��o�;�� C����h-c a, I,as owner of thct Misc.Contluits&Contluctors ��e tT ppperry,wi!!do:he�.vork and the structare Other See Com lete Fee Schedule' is net intended or cifered ior sale(Secfbn 7C44,Business p i— , anc Professions Code). �ti� '��� CONSTRUCTiON LEPIDING AGENCV I hereby affirm that ihere is 2 construction lending aaency for the ^erformance of the work for vihich this permit is issued(Scc.3097, pERIdIT FEE iSub-Totalj � � Civ.C.1. �,� PLAN CHECKING FEE Lenders Name PERMIT ISSUMG FEE a Lenders Address ,. I certify tnat i have read;his zpplic�tion and state tnst the aboe•e TOTAL FEE ��s informaticn Is cerreCt I agree io comply�mi?n all Cocmty ordinances and State lav!s regulating El�ctricai wiring, antl he2by authorize � � -� � - - - � � ' . _ ._ . .. . . .. . .. . ,.____,......._._.._..._.__. ..... _. ..__._. . ........ . . . representatiws of}his Ccunty to enter upon the above-mentioried� � � property for insp=c[ion purooses. SEE REVERSE FOR EXPLANATORY LANGUAGE ��:� Signature of Per e Date " ,�_'�..,...... ' .�.a.G..,�....-,,.-..:.„..aras.w�:..s.�...�,u,�. .. ,.-.. . .,,,,yi... .... .... ... .. _ . . -- - . _ __ -_--...__._.__ ._ _,. ....__._.._.'S ,. . , , .. . %, ., ,. . . ' ' � .. . . _ . . .. .... . � , ,. .. . � ... . _. ,..,. ..,.,... . .�, .. . . , . . . .,.. . ..- . . .. � ' .. 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