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HomeMy WebLinkAbout1296A '�� WORKERS'COMPENSATION DECLARATION 7GA663 t0/a1 � � �he�bY affirm that I have a certificate of consent to selt insufe, CE-806G APPLICATION FOR ELECTRICAL PERMIT or.3 CertifiCn'P,oF Work:rs Compensation Insumnce,or a certified COUNTY OF LOS ANGELES BWLDING AND SAFETY � /�L copy therelo�ff(Sea 3800.Lab.CJ PoPICY NO!�7�o2..�QomP�Y � ! FOq AVPLICANT TO FILI IN -' .108 �� �_ ❑ Certified copy is hereb fumished. , . EACH NO. . FEE AooaESS Y . . New Resitlential Bidgs.8 Poois '� Cerlified capy is tiled with the county buildirx3 inspection 1 d 2-Family,Sq.Ft. 5 -- S LOCAIJTY x - epart ent. � � � � �lulti-fami�y Sq.FL — 7oEnF7E57 CROSS 5T. �ate �P,pplicant-� L aY-[n�� Residential Swimming Pools - owNEN OR�("p` - �(! FIRM NRME�,1\7 r V L CERTIFICATE OF EXEMPTION FROM WORKERS' IJ -7 Outlets:Rec—L'ght�Swz—i ��� � . COM11PENSATION INSURANCE ��-�, � � , ,2p �� ' �'/"!) nooaESS ( (This section nead noi 6e completed if the work i�vdved by ihe First 20 Total No.� Additional CITY Tel.N /3 6� permit Is for one huntlred tlollars(5700)or Iess.) p�W CHECK � 1 certify that in the performanca of the work for whkh this permit � � �APfn.ICANT � is issued,I shall not emp�oy arcy person in arry manner.so as ro � betome subject to the Workers'Compensation Laws. - L'ghting Fixtures First 20 � ADDRESS � "- � � � � � TotalNo.� Additional GTY ��� TeI.No. � Date AOP��cant Flzed Appliances Not Over 1 HP NOTICE�TO APPLICANT: If, after.making this Certificate of PERMIT - ExemDlion,you shouitl become subject to fhe Workers'Compensal"ron Ran9e_.Heater_D.W. _ APa�icaNi � provisions of ihe Labor Code,you must forihwith comply with such Oven_ Dryer_ W.M._ � ADORESS a 64�� provisions or this permit shall be deemed rewked. Top _FAU W.H._ ����/ LICENSE�CONTNACTORS DECLARATION Hood�Fan �, Olher_ �� CITY Tel. b I hereby.alfirm that 1 am litensed under provisions of Chapter�3 sq1 � LICENSE �1 (commencing with Seclion 7000)of Division 3 of the Business and Disp. _Room Air Cond. _ REG.N�MBEf� V � � Ciass. Pf0�B55i0I15 C.Ode,and my liCenSf is In full for[e 2nd elfect. DI57FiICT NO. PROCESSEO BY Power Apparetus&Large Appliances - - �qy���Q `q, Size 8 TyPe H?.KW.KVA.or KVAR � � .... . �. .--� - ..- . . . �V . .. . . .�o. License Number�(Z_Lic.Class v Up to 1 Incl. � � ' FlNAL - � -- (� Over 1 to 10 Incl. DATE J �.. �l VAUDATION � ConlraCtor Date�.�� . . . FlNAL /} a ' - O Over 10 to 50 Incl. I am exemDt under Sec. Over 50 to 100 Inc. gy / �' W BSP.C.for[his�?2son � Over 100 `'� �.. . . ..-. . p„ Services,Swbd.,MCC d PanelhoaMs � - � � -� � N --- Date: 0-200 Amp.Under 600 V� ' � 0 ^ Sgna[ure 201-1000 Amp.Under 600 V� � � - � � � � - ❑ - � Over 1000 Amp.w Over 600 V Exemp[ion for Reg.Maint Elect. :�iz9.ba � � - -�- �- SINGLE FAMILY - � - Temp.Power Pole 8 Appurtenances , � HOME OWNER-BWLOER DECLARATION � � � n e • s 1 hereby atfirm that i am ezempt from the Contractor's License Law Sign with One Branch Cireuit `2 For the toltowinq reason ISenion 703L5,Busiross aM Professiona- Additional Siqn Branch Circuits Code): f + •5 J.2 5 ❑ I,as owner of the property,will do the work and the structure M�gc.Conduds d Conductors -�- � - - � e o a��i��_ is not intended or oftered For sale(Sedion 7D44,Business Other(See Complete Fce Schedule)_ antl Professions Cotle�. �--�-" - ' � � �� � -" � - - - � - - �Q�2-�7 ' CONSTRUCTION LENDING AGENCY � � � � � � �� -� - - .. . . .. I hereby alfirm that there is a constmction lending agency for the , performance of the work for which this permit is issued(Sec.3097, pERM1T FEE - � -���� I�b-Totap - � .. . . . . Civ.C.�. N 1 -� PLAN CHECKING FEE. . .... . _ Lender's Nahei V _ PERMIT ISSUING FEE ,. , _ _. �D Lender's Address I certify that I have read ihis appiication and state ihat iho a6ove . TOTAL FEE `j� information Is correct.I agree to comply with all County ordinances � and Stat regulating Eie rical wirirg,and he by authorize � represe ative of this Counly o enter upon the a ve-men�ioned'" ` � ' �- � �` � �� -" � � _ - .. . . ... ,.. . . . propert for in ection purpos s. � . .. .SEE REVERSE FOR ERPLANATORY LANGUAGE . . �Signatur Permittee ate 1 ..��3._...�.��._ , .._ �. . . � _' . i _'_ _ . .._. �'_._.�_.►�_ '_'.' "__�' " f .. ;. .,r., .i i � � j i ��Y- , � � , ! ri!G I � � � , � �/;,- '! 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