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HomeMy WebLinkAbout1426A (13) WORKERS':OMPENSATIONDECLARATION 76A663 ,o�s, qppLICATION FOR ELECTRICAL PERMIT {� I hereby atfirm that I 6ave a�ceititicate of consent to sell insure, CE-8o6G or a ceniticate of Workers'CompensaCron Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY LJ copy thereof(See.3600,Lab.C.J ^ Ld/[l �I Poiiey No.�?�Cpmparry N - FOR APPLIC0.N7 70 FlLL IN � JOa- � � EACH NO. -.-..FEE ��ESS ❑ Cer[ified copy is here6y furNshed. .. .. . , New Residential Bldgs.8 Pools "� � LOCALRY � -CeAified copy is fiied-with the��cwnty buildirg inspection 1 g 2•Family,Sq.FL S — � � . � tlepar nt. �� ' •� � � . ' ' Multi-family Sq.Ft. NEnRESi .-. /�f Resitlential Swimming Pools CPoss ST. . �'j DatO_�17��APPlicant Q�'�.[J/ Z__� . ... -. . OWNER OR' l�Y � L V vL FIRM NAME. � � CERlIFlCATE OF EXEMPT70N FROM WORKERS'��� ' putlets:Rec L'ght—Sw.— � • Mat� R .�� � ' �� COMPENSAiION INSURANCE� � '- '� . �' � PDDRESS `� '(This aeetbn need nM be eompleted H the work InvoMred 6y the Frst 20 . CITY Tel.N -permk h for aro hundred dollaro(5100)or less.) , � Total No.� Additional - (CBINfy fhBT If1 thE pBrfOfmanCB bt ih2 WOfk 10f WhiCh ihi9'pefmif ' PLAN CHECK /� .is luwed.I shall rwt empioy arry person in arry manner so as to - � ���M- - k� become subiect b the Workers'Compensation Laws. Lighting Fiztures First 20 . ADDPESS--- ----� . . .: ' Additional � '' �' �� � � ' '� � � � � Totai No. �� CITY � -�� � � ""�" . Tel. � Date .�. . ."APP���t. . .. . ,. .., Fxed APPliances Not Over 1 HP �NOiiCE.TO APPLICANT:-If,�after�making this Certi}icate of PERMir Range_Heater_ D W.__..,_ AP���`M ;Exemptan,you should become subject to the Workers'Compensal'ron � � �provisiore oF Ihe Labot Code,you must forthwi[h comply with such Oven_Drye�_ W.M._ ADDRESS �P�visions or�hia permit.shall be deemed rewked. . . . . ToP �FAU�_ W.H.._.. . . . __ ....- .. _ ._. . � - LICENSED CONTRACTORS DECLARATION�,, � Hood_Fan — Other_ CITY Tel.NoZ � � •I hereby affirm that�I am licensed under proviaons of Chapter 9 Disp.-—Room Air Cond.�_ -' -- � � -�-- uCE�+SE OR ,, . ..__.. . .-. Ctass.�-" �commencing with Section 7000)of Division 3 oF the Business and REG.Nl1M6ER �- Professions Code,and my license Is in full force an0 eHec[. power Apparatus 8 Lare�a Appliances- � . , . ois7aicr No. ef�ocesseo ev � ���O Size 8 Type HP,F(W,KVA,or KVAR � � Q LICenSe Number Lic.Class� ... .. ....UP[0 1 Incl. ... . ... . . .... . . .. . FINAL V � � � Over 1 to 10 Incl. DA� . VALIUATION � ��Conlractor � te� � � l ... ❑ Over 70 to 50lncl. � FINAL I am exempt under Sec. � � '�• -- Over 50 to�t001nc.- . � gy._.... _. . ,._..._ _�� [!2(�a_. W B%P.C.for this reason Over 100 #• • e o •� � . .._.. . _.---. .. ....:........ ... .. .. Services�Swtid.,MCC&Paneiboaids-.. .. .. .. . .. . ► - . . . . . - - ��--- ----._ .... ... Z Date: 0-200 Amp.Under 600 V � �' ° � J.J O .. .... . . . . _ . Sgaature ' 201-1000 Amp.Under 600 V - � � ��� ' � �-� � �-"-� �-"- _....... .._.__.. .._ .,. . . . _ _ . ❑ Over 1000 Amp.o�Ovef 600 V •° • � . J v i ExempYron for Reg.Maint.Elect. " -- ._ .___ . 0209-87 4 SINGLE FAMILY � _ Temp Povrer Pale&Appurtcnances . _ _ _. HOME OWNER-BUILDER DECLARATION g;g�with One Branch Circuit I herehy affirm that I am exempt from�he Coniractor's License Law Additional Sgn Branch Circuits--�- for the foilowirg reason�Section 7031.5,Business and Professions � "' "���� � ��� --� � CAde): . . . . . . _ . . . . .. . . . . .. _. .._.. ... _ . ❑ I,as owner of the property,wili do the vrork and the structure Misa Conduits&Conductors is not intended or oftered for sale(Section 7044,Business .. Other(See Complete Fee Schedule)_ � . .. .. . .. . . ...... .... . and Professions Code). ' CONSTflUCT10N LEND�NG AGENCY � �- - -- - � � - � �- �---- ��-��� � I hereby alfirm that there is a constructbn lerdirg agency(or the performance af the work for which this permi[is issued(Sec.3097, �pERMIT FEE� ��- - � �"--� �- �- - (Sub-Total� � � (� ' ��'�� ��� - � - Civ.C.). ..... . . _. ._. " ._. PLAN CHECKING FEE . .. ... . . ..-.. ... . ..-._ .-. . .._.._ . .._... . . .. .. Lender's Name . � -�� PERMR ISSUING FEE�-� - - - �- (� -��--- ��. � � � . . . _ LerMer's Address � I certify that 1 hav�e read this appiication and state tha[the above TOTAL FEE.. _._. . ___ ..._ . . _ . . .. � SO . _ . . .. _ . .. information is carect.I agree to compy with ali Cwnty ordinances � . and State laws regulaling Eiectrical wiring,and he�eby aNhorize . _.,. , . , .._. . . .. . � _ . . . _ . _ _ ..__ .. , sentatives of th' County to en r upon ihe above-mentioned ' rop ly for inspecti purposes. - SEE REVERSE FOR EXPLANATORV LANGUAGE-�� - . - . _ .... . .. ..... .. ..... .._. . . , � _� ature of r ttee Oate � � i'.... ..���`'.'.�.� `. _.. . ._ ..__... i-- -� i'. 'I'- --i..�_I-;..y;-' I I �..`�1 .. d,' , I ,rj' �r � i� i � I I C+- �r..-, I ;'_ .�. — i il � �r , I . r . � ' I I I ! ' f ` I ' I`' � . . j: j , , / �1t /F"� I I .f ; i �� r;.� '-' .. . ' _ � ; "" ' `f � j - � r-. ,i- ' . - ' j i.,. `� i . `-�'.� -- _ ` ; >>� � -c ; ' � � � -� . �` � � ,. .� u: .. 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