HomeMy WebLinkAbout1593A (16) WORKERS'COMPENSATIONDECLARATION � 76Ad63 �o�e, APPLICATION FOR ELECTRICAL PERMIT ��� � �
1 hereby affirm Ihol I hove a cerlifimfe of consent to self .�E'806(''.
� insure,or a certifica�e of Worke�s'Compensation Insurance, �OUNTY.OF LOS ANGELES BUILDING AND SAFETY�
or o te�iified copy thereof(Set.3800,Lab.C.) �
P❑olity No. Campany FOR A�PLICAHT TO FRl IN JOB f� ' �
Certified co is hereb furnished. E/.CH NO. FEE ADDRE55 o�a�d J�
PY Y New Residemiol Bldgs.8 Pools
❑ . 1 8 2-Famil — LOCALITY �
Certified copy is{iled with Ihe co�nty building inspeo Y.54�F�� E — s A QN
NEAREST
tion deportment � � � M�III-Tomily Sq.N. �
ceoss sT. A Ncr C.'.
Date Applicant � - Residential Swimming Poals OwNER O�t �
� � . FIRM NAME �✓ L p iy�N�
CERTIFICATE OF EXEMPTION FROM WORKERS' htnR �
Oudets�Rec_lighr_Sw._ '^p
COMPENSATION INSURANCE� First 20 ADDRE55.7�p-.S• nTLq�vr�c VD
(This s�ctlon nsad not b�eomplet�d tf Ih�work involvod hy Total No. Additional ��TMMo�✓Te,�e /'/9 Tel.No. J.�
Iha permlf It lor on�h�ndred dollars{5100)or I���.) .
I certify Ihot in ihe performonce o{Ihe work for which this qppNj�Cq�K , _
parmit is issued,I shall not employ any person in any monner .
so as b 6ecome su6ject to the Workeri Compensation Laws. � Lighting Fiztures Fi�st 20 A�DRESS �
� ���-����/ T Total No. Addilional
Date�Applicom.Ua'F E�ec:,�ic. CITY - � Tel.No.
NOTICE TO APPLICANT: If, after makin this Certif�cate of Fi.ed Applionces Not Over 1 HP� PEkMiT
E.emption,�yoo should betome sobject to �he Workers' Range_Hea�er_D.W._. APatiCAnli ,� E Lec,- /G
Compensalion provi5ions of�he lobor Code;you mus�forth- Oven _Dryer _W.M._ ADDRESS � � A�Q eN � G7�• �
with tomply wilh such provisions or Ihis permil sholl be Top _FAU —W.H._
deemed revoked. Hood _Fon � _Other_ ��TM �Ni H J� Tel.No. � -��y�
. IICENSE�CONTRACTORS DECLARATIDN LICENSE OR
I hereby offirm thot I om 1lcensed under pravisions of Chapter 9 � Disp. —Room Air Cond. � ReG.NUMBER 3 Closs.C/D ,
(rommencing wilh Section 7000)of Division 3 of the 8osiness � DISTRICT NO. PROCE D BY
ond Professions Code,and my license is in full force ond effect. Power Apparotus 8 Large Appliante5 , . . �
/1 Size 8 Type HP,KW,KVA,or KVAR� - • Q � �
License Number 3 y�s9�2 �ic.[lass y�� � � (� p�Nq� � - -- - .� V
Up to 1 Incl.
�-�:�ELec�R�c �^�7'[�y Over 1 to IO lnd. DATE � �U�f� VALIOATION Q
Con�rocla Date Over 10 to SO Incl. � �
OFINAL ~ '
I om exempl under Sec. Over 50�0 100 Inc.. . 6Y a+
� B.SP.C.for this reason �°P��� �t������/ - - '�
. � $ervices,Swbd.,MCC 8 Panelboords - . ► � � - ?
. Oate: _ Under 600 V [� .o
Si noture 201-1000 m .Under 600 V � ��� � /t�� /"�''��.�' • +
9 �e� mn.o,o�e�aoo v �1 5 9.3 A +
� E.emption for Reg.Moin�,Eled. � � � � .�e �-� e��.Z I
SINGLE FAMILY � Temp.Power Pole 8 Appwlenances �
HOME OWNER-BUILDER DECIARAT10N Siqn with One Branch Circuit � � • �4 8'S��
I hereb o(firm that I om exem t from the Comrocror's License paa;�;�����;� p,,,nch C�rru�ts • •
Law far the followinq reason(Section 7031.5,Business ond - �� - � � � . - •4&5 Q��
Professions Code�: -
� Misc.Condulls 8 Conductors ..�2�.7-$4
I,os owner of the property,will do the work and the
structure is no�in�ended or ofFered for sole(Sedion Other(See Camplete Fee Schedole)_ ► �
7044,Business and Prolessions Code). ' - �� '
CONSTRUCTION IENDING AGENCY . '�
I here6y offirm tha��here is a mnstruction lending agency far _ � ' � .
�he performonca of ihe work for which this permi�is issued pERMIT FEE - � - (Sub-Total) 3 D� .
(Set.3097,Civ.C.J. ' .
G H � PIAN CHECKING FEE� - � - � - - �
lender's Nome"`�� �! 9 .
S���C/�NG+C/ C_' Ve PERMIT ISSU�NG FEE . . p +� ,
Lender's Address L/'� /��-�'1 / ' �
I certify that I have read this opplimtion a d s�ote thot the . TOTAI FEE L��,y ,
above informalion is corrett.I agree to comply wi�h oll Coumy , -
ord�nonces and State laws regula�ing Electrical wirinq,and
hereby aorhori; re resentalives oi ihis County�o enier upon -� - �� � � � � - � - .
t above- �on o for i ection purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
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