HomeMy WebLinkAbout0931A (9) WORKERS'COMPENSATION DECLARATION r 76A663 ,o�e, APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affi�m Ihat I have o tertificale of mnsent Io self ��E'�' . � � .
inwre,or a cerrificate of Wo�kers'Compensarion Insurance, j COUNTY OF LOS ANGELES u BUILDING AND SAFETY
or a ces2rt�if,ied copy Jereof(Sec.3800,Lab.C.) ` . � � TI � �
��!.�J 7�LS �Ty�T6 T'uNp FOR APPIIUM TO iILL IN JOB
P�o icy rvo. Campany y a
Certiiied copy is hereby furnished. New Resfdential Bldgs.8 Pools EACH NO. FEE ADDRESS �� S•y1�N0 !V,
� Certified copy is filed with the coonty building inspec- 1 8 2-Family,Sq.Ft s = f LOCALITY FlHON� 2
tion department. Mul�i•family Sq.FI. NEnkEST
f_L�—� �.[,����A/N(� Residentiol$wimming Pools � CROSS ST. Nv0 �` [L° Q
Dale Applicant OwNER OR
FIRM NAME
� CERTIFICATE OF EXEMPTION FROM WORKERS' � � � /rwa '
COMPENSATION INSURANCE Outlets:Rec.�]�Light Sw._ �y `� qpoRESS �
This aecfion nwd nol ba com lehd tf fh�work Inrohad b F�rst 20 � �
� P Y Total No.�s CITY . Tel.No.
th�parmiT 1�for ono hundr�d dollan(5100)or I�ss.) Additionol 1
I certify Iha�In ihe performonce of the work for which this - q�N�qN7K - .
permit is issued,I sholl not employ any person in any monner
so as to become subject to the Workers'Compansolion laws. Lighting Fiztures First 20 � i� ADDRESS �
- Total No. Additional
� � _�` CITY Tel.No.
Doie eppliconl ' Fi.ed Applionces Not Over 1 HP PFRMIT
NOTICE TO APPLICANT: If, a(ter making Ihis Certificale of APM�G4NT E'd�, d•
Exemplion, you should become subjed �o the Workers' Ro^9e�Heoter_D.W._ _ .
Compensation provisions of the Lobor Code,you musl forlh• Oven .�.Dryer W.M.— A�DRESS S E �
wi�h camply with such provisionz or Ihis permil sholl be To —FAU �W.H.—
deemed revoked. . Hood Fan CITY 6T' � Tel.No.y'�y 7� `' �
LICENSED CONTRACTORS DECLARATION --1C �Other_ i1�h u�NSE�Q
I hCreby affirm ihot I am licensed under provisions of Chopler 9 Disp. �Room Air Cond. — ��A�' REG.NVMBER Z(p Class. B_�
(tommenting w��h Sedion 7000)oi Division 3 of the Business � powar Apporotus 8 Large Appliontes DISTRICT NO. �Q PROCESSEO BY �
ond Professions Code,and m license is in full force and effect. �
/ 'Site 8 Type HP,KW,KVA,or KVAR� Q
License Number 3�7SZv Li[.Closs� Up�0 1 Incl. FINAL - � V �
/� 'Over 1 to 10 Incl. DATE ���Q ��,( VAUDATION Q
Ef'�- LSLi�I�T�C Dote I— g—�9 1 y �
Contractor O�er 70 to 50 Incl. , ' �" �
❑ FINAL V
I am exempt under Sec. Over 50 to 100 Inc. BY a
8.8P.C.for thiz reason � Over 100 {��' Z
� Date: Servites,Swbd.,MCC&Ponelboards � -
0-400 Amp.Under 600 V .
Signature 201-1000 Amp.Under 60 1� -� -
❑ Over m . ver 600 V - �
Exempiion for Reg.Moin1,Elec�.
SINGIE FAMILY Txmp.Powar Pole 8 Appurlenances . . . _ .
- HOME OWNER-BUIIDER DECLARATION Sign with One Bronch Circuit � � ��
I hereby offirm tha�I am exemp7 from the Contraclar's License Additional Sign Branth Cirtvils �
Law for ihe follawinq reason($ection 7031.5,Business nnd . � i
Professions Code): � � � -
❑ I,az owner of the properfy,will do Ihe work and the Misa Conduils B Conductors �0 Cl�.� A �
structure is no�imended or offered for sale(Saction Other(See Comple�a Pee Schedule)_ ► �� � � � �2 � ,
7044,8usiness and Prolessians CodeJ. �
CONSTRUCTION LENDING AGENCY I • � � $5 O '
i
�hereby offirm 7hot there is o mnstruction lending agency for . s ,� ,� a S O U.
the performance af tha work for which this permit is issued PERMIT FEE (Sub-Totol) � � � -
(Set.3097,Civ.C.} � .
� � PLAN CHECKING FEE -� � � � . ��'�9—8 4
lender's Name � � - � J
� PERMIT ISSUING FEE . � �
�� Lender's Address � -
'�I�ertify that I have reod�his opplimtion and sfare that ihe TOTAL FEE . � � �
��,obove informo�ion is corred.I agree to tomply wi�h all Counry
'ordinances and$ate laws reguloting Electriml wiring,ond � -
hereby ouihorize repr entotives oF Ihis Counfy to enter upon �
he o60 � ntione r perly(or inspec�ion purposes �
'+�_�� SEE REVERSE FOR EXPLANATORY LANGUAGE _ ,
\
�no ure of Pe iltee Date � ��\
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