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HomeMy WebLinkAbout1296A (22) WORKERS'COMPENSATIONDECLARATION 76nE63 +o�e, qppLICATION FOR ELECTRiCAL PERMiT �� I hereby aff�m Ihat I have a certificate of consent to self insme, CE-Boe� oca ce�tilicate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy theieof(Sec.3800,Lab.G) � Policy No.1�tZ Comparry � FOR APPIICANT TO FILL IN �� � JOB (' ❑ Certified Copy is hereby furnished. EACH NO. FEE ADDRESS f J- �� . New Residential Bldgs.8 Pools . �� Certified copy is filed with the county building inspedion 1 8 2-Family,Sq.FL S — S LOCALITY � . dep�fm nt - . Multi•tamily Sq.Ft. — NeMEST -7 � CRO55 5T. ��(�2�/U Residentiai Swimming Pools � DatE APPlicanf- V �� � � . . . qNMEf10R FIRM NAME 'U L 1� � . CE IFICATE OF EXEMPiION FROM WORKERS' . � Outkts:Re Light SW. MAIL � COMPENSATION INSURANCE . r S /� l� /jL AppRESS (This secilon neetl not be eomp�etad il the work Involved by the First 20 , permit Is tor one hundrad dollars($100)or lesa.) Total No.� Additional CITY Tel.No. .I certify that in the perlormanCe of th2 WOrk 1or which this permit � ' PLAN CHECK ���j,�.-` �is issued,I shall not employ any person in any manner so as to �1. APPLICANT� ��.�.IV 6ecome subject to the Workers'Compensation I.aws.� L'ghting Fixlurfe�s 1I First 20. .G-�' �� ADDRESS I � 1 Total No.J.� Additional U CITV � ��y� Tel.No.^� Date AppliCant � V 1 �1 / Y �E-.TO APPLICANT: If, aftei.mzking�this Certificale of Fizetl Appliances Not Over i HP pERMiT L �tion,you shauld become subject to Ihe Wo�kers'Compensation Range_Heater� D.W, _ APR.�C!`NT provisions of Ihe Lebor Code,you must fortMvi;h comply with such Oven_Dryer_ W.M._ - �� � AD�RESS � � provisions or this permit 5ha11 be decm?d rewked. Top _FAl1 _W.H._ LICENSED CONTRACTDRS DECLARATION � Hood_ Fan _Other_ ��N � � Tel.No � -I hereby alfirm that I am licensed undei provisions of Ch'apter 9 UCENSE oH �j � '(cOmmfnCing with SeC�ion 7000)C1 Divi5i0�3 01 Ihe Bu51ne55 end ��Oi5(z �_ROOtiI Aif COnd. _ REG.NUMBER "� �` � Class. Protessions Code,ard my license is in fu�I force 2nd effeCt pISTRICT NO. aOCESSED 9v Povrer Apparatus&Large Appliances y: �.. /.(l�� , � Size 8 Type HP,KW,KVA,or KVAR � n License Number ��t b b Lic.Class - Up to 7 Incl. -- � - FlNAL� � a Contractoi� ��vrw V-G p�t�� �a'er 7 to 101nc1. DATE VALIDA710N Q . ❑ Over 10�o SO lncl. FINAC V I am exempt under Sec. Over 50 to 100 Inc, gy � B.BP.C.for this reason Over 100 � . � Services,Swbd..MCC 8 Panelboarcls ���� �-� �� � � � �� .. . . . . . Z - Date� -200 Amp.lJnder 600 V SiSnz!ure 201-1 00 Amp.Untler V - - -d - - - - . . � '����� --� � ' Over 7000 Amp.or Over 600 ❑ � Exemption tor Reg.Maint[lect. . . . .. ._ _ .. . � ' - -��SfNGLE FAMILY�--��� � -- - �" " Temp.Power Pole 8 Appurtenarices HOMF p�yNER-BLIIIDER OCCLARATION Sign with One 6ranch Circui} � )by aifirm that 1 am exempt irom tho Contractor's License Law � � � 2 9,b� fo.�:ne foilowirg reason(Section 7037.3,Business and Aofessions Adtlitional Sign Brench Cirevifs - Codel: _.. . .. _ �• . • • 02 . ❑ 1,as owner of the property,will do the work and Ihe structure ��isa Conduits 8 Conductors - � � � . 1 4 1,5 0 is not inleMed or offered for sa�e(Section 70a4,BuSiness 0'her(See Complele Fee ScheduleJ_ - , and Pro(essions Cotle). - --�� - � - � � - ,� - � - • • � 4���J�� CONSTRUCTIDN LEN�ING AGENCY - . . ... ....� _ 0 a 3� —8$ I hereby affirm that there is a tonstmction Iendirg agenty for the perlormance of the work for which this permit is issued(Sec.3097, pERMR FEE � -(Sub-To[al) ? Civ.C.1. . ... . _ � .. . . . . . . . . PLAN CNECKING FEE . , Lendcr's Name �� �� ��-� � � � PER69T ISSUING FEE . O Lentler's Adtlress � I aertify that I have read fhis application and state Ihat the a6ove TOTAL FEE J �♦S informafan is correct.I agme to comply with all Cwnry ordinances � -" - an fe laws reguiating EleMrical wiring,and hereby authorize ' re ese t2lives of this Count to eMer upon the above-manlioned- -� -- � - �� -- � - - � - - - � � �- � � � pr erty for inspection purp s 5. � �� ` � , , SEE REVERSE FOR E%PLANATORY LANGUAGE. _ _ _ . , Sign �re of Permiu�e Date � � •..,...�^�."._. L� "".�� t_—�y/ �-- —.�- ..f.. _' -I•- �_ -' i ; I —i�._'i j'-L^': - j I� , j I � , ! � � � � — '� i ; �� �' i �i.,i-;, '. 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