HomeMy WebLinkAbout1596A (15) WORKERS'COMPENSATIONDECLARATION � 76A663 �o�e� APPLICATION FOR ELECTRICAL PERMIT ��� � �
I hereby af}irm Ihot I have a certificale of consenl�o self �'�� . ��
insure,or a certiftcate of Workers'Compensation Insurance, COIJNTY OF LOS ANGELES BUILDING AND SAFETY�( `
or a tertified mpy ihereof�Set.3800,Lob.C.) - ,
P❑olicy No. Company FOR APPLIGM TO FllL IN qppRE55 , /� ON [/,
Certified copy is hereby furnished. New Residentiol Bldgs.8 Pools EaCH n�0. FEE
� - 1 8 2-Fomil Ft, s — 5 IOCALIN � �
Certifiad topy is filed wilh the county building inipae- Y•S9•
fion depa�lmenl. Multi•family Sq.Ft.� — NEAREST !�
� Residentiol Swimming Pools , ONTIER OR �4J - u
Date Appiicant � �
`/ - FIRM NAME .R'T �-�2�� ��
. CERTIFICATE OF EXEMPTION FROM WORKERS' Outle�s:Ret�Light j�Sw�
COMPENSATION INSURANCE � O ooRESS a�. TG A-�v r�c L f� ,
First 20
(Thls sacfton nasd nof 6e complafad I(fha work involv�d by 7oiol No.� Addilional O� CITY o Te,pe � Tel.No.a�3- - tJ/5/C
fhe parmit is for one hundred dellan(5100)er lett.)
PLAN CHECK
I certify that in the performance of the work for which Ihis � � aVpLICANT �
permit is iss�ed,I shall nat employ any person in ony monner
so as to become subject to the Warkers'Compenso�ion laws. lighiing Fi.t�res First 20 �`S ADDRE55
Addi�ional
Do�e: //r-�/p(/ 7��=EL ec r�r'i� Total No. CITY Tel.No.
E�GL.L.�.Q�APPlicant� FiKed Appliontes Not Over 1 HP PERMIT
NOTIC TO/APPIICANT: If, ofler moking this Cartificate of � APPtiCANT �-F EL ec i 1ri
Exemption, you should become subject to Ihe Workers' Ronge_Healer_D.W.—
Compenso�ion provisions of the lobor Code,you must forlh• Oven _Dryer —W.M. ADDRE55 � ��A. C%
with comply ith such provisions or this permit sholl be Top _FAU —W.H.Z CITY Tel.No. �
deemed revoked. � - . /VT/��/U 7 � ��
Hood _Fan _Othe�_
� UCENSED CONTRACTORS DECIARATION - LiCEn75E OR
I hereby aHirm thot I am licensed under provisions of Chapter 9 Disp.�—Room Air Cond. — REG.NUMBER Closs.
. �commencing with$ec��on 7000)of Division 3 of Ihe 8usinass DISTRICT NO. PROCE BY y
Power Apparalus 8 Lo�ge Applionces
. ond Professions Code,and my license is in full{orce and eHed. � e�� O. .
. r� Size Type HV,KW,KVA,or KVAR� l � �
license Number 3�/.3.7��� Lic.Closs� _�. � C�'.1 FINAL . ' ' � V �
Up to 1 Incl. DATE a'
' a Over 1 l0 10 Incl. a.� �� VAIIDATION Q
Contracior��F���C%�/�Da�e � �� �
❑ Ovar 10 to 50 Ind. FINAL `� . . . ll
I am exempt under Sec. Over 50 to 100 Inc. BY W
�� d
' Ovar 100 y
. B.BP.C.for this reason � 2
. Serv' MCC 8 Panelboards . .... . . -
Date: 0-2W Amp. nder 600 V � OG .
� $ignature mp.Under600V . - ��� ����
7 Over 1000 Amp.or Ovar 6pp V
Exemption for�Reg.Maint.Elect.
� SINGLE FAMILY Temp.Power Pole B Appur�enances . .. _ . .
HOME OWNER-BURDER DECtARATION - Sign wi�h One Bronch Circuit � .
iereby afiirm that I am exempt from the Conlroc�or's Licenae Add�+�n�nl Sir�n Hmnrh Grcuih �� � � �
�w inr ihe folfowing reoson(Sec�ion 7031.5,Sus�ness and �� 5 9.6 A
oiessions Code): - -
� M;sc.Conduits 8 Conductors - � � '�-
I,as owner of the property,will da the work and tfie t;� � • •2 ,
structure is not intended or oNerad for sale(Sectian . Other(See Complele Fee Schedole)— �
' 7044,Business and Proiesslons Code). , � • •6 0.7 5
CONSTRl1CTION LENDING AGENCY � - . . • s �6 Q'�J�
,re6y oifirm that there is a mnstruUion lending egency for . � �
performonce ai the work far whith Ihis pe�mit i5�55ued PERMIT FEE - (Sob-Totpl) J/Q 3 - � - �2,� �]�8 4���
'..3097.Civ.C.). � .
N�rOMO BAA/� P�N CHECKING FEE
_
ler's Name � � �
'f7�n/9NIo��V_/-�/�i/2 pERM1T ISSUING FEE - . �O G
er's Address �/ �'GN� C�. /" �
ify thal I have reod this npplicotion and stote thot�he TOTAL FEE y0• JS
r in(ormotion is correct.I agree to comply with all Counfy
�ntes ond 51ote Iaws regulating EleUrical wiring,ond . , ,
y authorize re resenlatives of Ihis ounty to enler upon , �
�ove-m ion ,property for in dion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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