HomeMy WebLinkAbout1397A WORKERS'COMPENSATIONDECIARATION � 76A667 �o,e� APPLICATION FOR E ECTRICAL PERMIT . �� [�
I hereby affirm Ihat I have a cerlifitate of consent to self �E-80C(' II
ins�re,or a cerrifico�e of Workers'Compensaron Insuronce, { C�UNTV Of l05 ANGELES BUILDING AND SAFETY jj
or a certi♦f�i�ed��J%��p�y��h�e�reaf(Sec 380�0/,Lab.C.) ^ �
P❑ol�ity N�OmpOny Y!/!�/�iP1G/�1 � FOR APVLICANT TO FILL IN JOB �.7�O A
Cer�ified copy is hereby furnished. � New Residentiol Bldgs.8 Pools EACH NO. FEE ADDRE55 ��• D�� �'v lSQZ
�-Certified copy is iiled with Ihe county building insper � �&Z-Family,Sq.FI. E = S LO[ALITY n�Qryy�d�} . �Q/(� �j
tion depo�imen�. � Mulli-fomliy$q.Ft. NEAREST
, �Ro55 5T. G r�a y� v-e
A� Residential Swimming Pools OWNER OR
Date pplicanV���� • �� C FIRMNAME E� GLDULIA�
ERTIFICATE OF EXEMPTION FROM W RKERS' I OWlels:Rec_light_$w,_ ��ij g 7 Ln QSG a�/ ,µ Z
- COMPENSATION INSURANCE D�RE55 E /�- J�l 7t"I
Firi1 20 n
(Thtt c�cRon n�ed nof 6�compl�t�d if rh�work tnvolvad by ; Total No. Additional CITY � ��(.ES `�T .No. � ,..6 -0��
}ha p�rm�f I�for one hundr�d dollan(f100)or Iest.� ' PLAN CHECK �^
I certify fhot in the pe�iormance of�he work for wMch Ihis '� I APPIICANT
permit is iss�ed,I shall not employ any person in any manner �I .. �
so os fo 6etome subjecf fo ihe Workers'Compensation Laws. � lighting FiKiures First 20 ADDRESS .
� Totol No. Additional p CITY — - Tel.No. �
Dote Appiicont - Fiaed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, af�er making ihis Certificale of � � qppMjl�p,NT c � l C�
E.emplion, you should 6ecome su6jec� to �he Worke�s' Ronge_Hea�er_D.W._ �
Compensotion provisions of the Lobor Code,you must forth- Oven _Dryer _W.M.— ' ADDRESS
with Comply with such pravisions or this�permit sholl be 7pp _FAU —W.H._
deemed revoked. � � Hood _Fon _Other_ ��TY Tel.N �r�S i�1 O
LICENSED CONTRACTORS DECLARATION UCENSE OR `
I hereby affirm ihot I am licensed under piovisions of Chopfer 9 Disp. _Room Air Cond. _ REG.NUMBE �Q�7 C��=S•�+'�v
}
.(cammencing with Secfion 7000)01 Division 3 of the Businets DISTRICT NO. PROCESSED BY � 0-
ond Professions Code,and m license is in full forca and effect. Power Apparatuz 8 Large Appliances O
�,3,3 O�7 )i Size 8 Type HP,KW,KVA,or KVAR- t O .�t� �
License Numb .Class � � Up to 1 Incl. fINAI///'''��� n
DATE t/'y, V ��� �
' Over 1 to IO lnd. - � J� � VALIDAT�ON V
Conhacto 1e' Over 10 fo 50 Incl. W
❑ FINAL + a
I om ezemp�under Sec. Over 50 to 100 Inc. BY ``�I\I �1 3 9.7 A �
B.BP.C.for this reason Over I00 � � J �•.•.. • .2 Z .
Dote: Services,Swbd.,MCC 8 Panelboards �
0-'l00 Amp.lJnder 6W V � d •G ra Jr O
Signature 201-1000 Amp.Under 600 V
OOver 1000 Amp.or Over 600 V s e e z 5 6 6�
E.empiion for Reg.MaiM.Elecr. �r
SINGLE FAMILY - Temp.Power Pole 8 Appurtenonces � ' ��2 8�8 6 '
HOME OWNER-BUIL�ER DECLARATION $�9�wilh One Bronch Circuit
I hereby affirm that I om ezempt irom the Coniractor's license qddirional Sign Branch Circvits
low for the following reason(Secrion 7031.5,Business and - �
Professions Code): � .
❑ I,as owner of�he property,will do the work and Ihe � Misc.Conduirs 8 Canductors �
sfruUure is not intended or aifered for sale(Section � Other(See Complele Fee Schedole)_ ► �
70d4,Business and Professions CodeJ.
CONSTRUCTION LENDING AGENCY
I hereby affirm ihat�here is a construdion lending ogency for _ .
the perio�mance of�he work for which this permif is issued ' PERMIT FEE � � (Su6-Totol) �
(Sec 3097,Civ.C.).
PIAN CHECKING FEE - �p
Lender's Nome � S
PERMIT ISSUING FEE
lendei s Address
I tertify thot I have read�his application and s�a�e ihat tha TOTAI FEE � �
obove informo�ion is corrett.I agree to comply with oll County � � - .
dinonces Slat w re ulating Elettrical wiring,and . '
�y ut r-e r re e to es of this Couniy lo enre�upon �
t -m �ia e p y for inspec�ion purposes. '
/ � � Q/ SEE REVERSE FOR E%PLANATORY LANGUAGE
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