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HomeMy WebLinkAbout1053A (7) WORKERS'COMPENSATIONDECLARATION 76A883 +o�e, qppUCATION FOR ELECTRICAL PERMIT � � I he,eby al(irm that I have a ccrti(icale of consent to self insure, CE-eoeG or a certificate of Workers'Compensatbn Insurence,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY y� copy thereof(Sec.3BOO.Lab.C.) TT' pplicy No.rk�?�n. COmpany ' FOR APPLICANT TO FlLL W � . JOB . 7 ❑ CertiFied copy is hereb furnished. . EACH NO. FEE fl�ORESS � � � L Y New Residential Bldgs.8 Pools ��� Certified copy is filed wilh the county building inspection 1 8 2•Family,Sq.FL S — S LOCALITY � y . depariment _ Multi-family Sq.Ft. — NEMEST. I � CRO55 SL � �Date�� .App!"want � �c.-��Zr' Residential Swimmirg ols+' - OWNER OR ` �� � FIRM NAME . CERTIFICATE OF EXEMPTION FROM WORKERS' ��- MAIL /1 COMPENSATION INSURANCE - � �utlets:Reor JtL L'ght Sw. aDDaESS / �.(This sectbn need not be compkled if the work Invo�ved by lhe � Frst 20 �. - - '��� . permit is for one hundretl dollars f$100)or less.) Total No.� Additional.. ` CITY F�. o. .I certify that in�the performance of the work for which this permit Pv.r�Ct�ECK • is issued.I shall not empby erry person in ary manner so as to �- �� APauCnuT•� � ��become subjed to the Workers'Compensation Laws.- � L'ghtirg Fixtures�� F�st 20 .-_ � AODRESS � Adtlitional �' ) - . - � TotalN� . . .. CITY.-.. TeI.No. Date � � Applitant Flxed Appliances Not Over 1 HP � NOTICE TO APPUCANT: If, alte�.making this Cer[ificale o1 PEaMiT �� �� .�i Exemption,you should become sublect to ihe Workers Compensation Rargo_Heater_D W. _ PPPIJCAM .provisions of the Labor Code,you must forthwith comply with such � Oven� ye� � �� � - - � A�DRESS - " � � j '- .. _ Dr r_ W.M._ . provisions or[his p=rmil sh�!I 6e Ceemed rewked. Top _ FAU _ W.H._ . . _ . .. .. . CITV � - 7e1.No. b LICENSED CONTRACTOflS DECLARATION Nooa_Fa� _Othet_ 'I here6y affirm that I am licensetl uMer provisions of Chapter 9 Ois LICENSE OR (commencing with Section T000)01 Divi'sian 3 of the Business and p"—RODnI Aif CAfId. _ REG.NUMBER Ctass.. PfOfeS5�on5 C.Ode,and rtn/Ii�enSC 15 in�ull fOICB efld effCCt. DISTRI�'T NO. PFiDCESSED B Power Apparetus&Large Appliances _ � _ � O �M^ ^ p r Siie&TypB HP,KW,KVA,oi KVAR ��Lic.Ciass�_ � `.'� � License Number Up to 7 Incl. ���� �� � - � - FINAL � � Over 1 to 101nc1. DATE VALI�ATION Q �Contmctor��Date�� ��' Over 10 to 50 Incl. � � - " - U FlNAL' ❑ 1 am exempt unCer Sec. Over 50 to 100 Inc. gY W � . . � a 6.dP.C.for this reason Over 700 N - Sej�es Pan rtls . . . � -.. . . . . .. . __ . . Z - - Date: 1 0-200 Amp.Under 600 V � r' Sign2ture � }201-10 p. er - � _ . . . . ... . ... . . - - � � � � � � � - Over 7000 Amp,or Over 600 V ❑ Exemption for Reg.Malnt.Elect .. . _ _ � �'" '�� �'�-� � SINGLE FAMILV � -�-� - � � Temp.Povrer Pole&AFPurt=nances HOME 01NNER-BUILDER DECLARATION Sign with One Branch Circuit � � � �� ��- -� I hereby at(irm th2t I am exempt from the Contractors License Law qdditional Sign Branch Circuits (or the fonowing reason(Section 703L5,Business and Professions - . .... . _ . . _ . . , Codc): � � - Misa Conduits&Corductors � - - - -� - - . ... I,as owner of the property,will do the work and the 5trucNre p�her(See Comp�ete Fee Schedule is not in!enCed or offered for sale(Section 7044,Business 1— ► , ,�� C ra J A and Piofessions Code�. - - " - � CONSTRUCTION LENDING AGENCY - - . . ... . . . . . _ . �J• • • • •2 I here6y alfirm that there is a constroction lendirg agency for ihe perlormance of the work for which this permit is issuetl(Sec.3097,... PERMIT FEE - - -�-� �-� . (Su6•Tolal) . . . ... ' . _ � • •7 a 2 5 a�.c.). � .PLAN CHECKING FEE , . . . . � " ^7 5.!J u Lenders Name pERMIT ISSUING FEE �� � , b S P�J-H H LeMer's Address . I certify that I ham iead Ihis application and state that the above TOTAL FEE �S� informalion is correct.I agme to comply with all County ordinances � �-� �� - � � � � � and State laws regulaUng EIr�Ctrical win ,and hereby authorize � repre nt ives oF Ihis �nty to-entei pon the ab -mentbned - � �� - ' '� � � � � -- - -�- - . prop ty( inspection p poses. � � �^ . 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