HomeMy WebLinkAbout1598A � _. _ �
WORKERS'COMPENSAiION pECLARATION I 76A669 �o,e� � APPLICATION FOR ELECTRICAL PERMIT �/�/� . �
I hereby oFfirm ihat I hove a ce��ifica�e of consant�o self �'�
ins�re,or a cer�i(icate of Workeri Compensarion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY f��
or a cartified copy�hereof(Sec.3800,Lab.C.)
POolicy No. Compony - . FOR 0.P►tl[AM TO FILL IN JOB �1 �` /� /
Certified copy is hereby furnished. New Residentiol Bldgs.8 PoolS EACH NO. � ADDRE55 d.7�J�✓J//9/�/�/V(� 4�/.Q.
❑ LOCALITY
Certified copy is F�led with ihe counry building fnspec- 1 8 2-Family,$q.F�. S — f p^f
tion deporlment. - Multi-/amlly Sq.Ft. — NEAREST
� � Rasidential Swimming Pools pwh�ER OR n veNu�
Dale Applitant � - . p
FIRMNAME C. . _✓y�jJ C/I//
CER7IFICATE OF EXEMPTION FROM WORKERS' � g � � irWi�
Oulle�s:Ret.�Li h Sw.
COMPENSATION INSURANCE ' � � Firs120 � QQ AODRf55 /L T/G D•
Thi�-�Mfon n��d not 6�eom lefed if fh�work inrolwd b '�-
� P Y Total No.�_ Additionol � S CITY r� e Tel.No. _
ths permif i�ler on�hundred doltars(SI00)or lazs.) � �
I certify fhat in the performance of the work for which ihis p���qNTK
pe�mit is issued,1 shall not employ any parson in any monner p�
so as lo become subject to the Workers'Compenwfion Lows. ti9hling Fix�ures Firsf 20 � ADORESS �
Totol No..�_ Additio�al 00
Doie�PP�,�e��.�FELec�-z�ic CITY Tel.No.
NOTICE O PIICANT: li, oFier making this Certificate oi Fixed Appliances Not Over I HP pERµ�T
Exemption, you should become subject to fhe Workers' Range_Heoler__�.W._ APPLI[AM �a-F EL ec r /G
Compensotion provisions of the lobor Code,yo�m�st forih- Oven _Dryer _W.M. ADDRE55 � GO ���1Q�+��� C /
with comply wiih such p.o�isions or this permif shall be Top _FAU _W.H.�
deemed revoked. � - � � Hood _Fan _Other_ CIN D�j� �� Tel.No. _ �
-LICENSEU CONTRACTORS DECLARATION �
I hereby offi�m thot I om licensed under provisiona of Chople�9 Disp. �Room Air Cond. — � R GN UBER 3 ,S � Closs.��0 .
(commencing with Seclion 7000)of Oivia(on 3 0(the 6usiness DISTRICT NO. PROCESSED Y .
ond Professions Code,and my licanse is in full force ond effect. Powe�Apparalus 8 Lorge Appliances , . _ __.. D �
jU p Size 8 Type HP,KW.KVA,or KVAR� � -u�'�� p
license Num6er-.LJ•3S/o� Lia Clpss ��O �� OD FINAL V ,
Up to 1 Incl.
Contracfoc.,(Ld'+' L��G�'P�Dote a � Over 1�o 101nd. DAiE a �� 1) VAIIDATION �
A"
❑ . Over 10 to 501nd. FINAL
I am exempt under Set. Over 50 to 100 Inc. BY /�/� W
8.8P.C.for this reoson Over 100 �V�-L' Q't'`�— , N '
� $erv'��,,,�� MCC 8 Panelboards � � � � Z
Date: �0-'!00�A�jmp.Under 600 V - �
Signaiure .. 201-�- I�p.Under 600 V- � � _ �
❑ Over 1000 Amp.or Over 600 V . -
Exemption for Reg.Mainl.Elect.
$INGLE FAMILV Temp.Power Pote 8 Appurtenantes � . . "� 5 9 8 A
HOME OWNER-BUILDER DECLARATION Sign with One Bronch Circuit �� � � � �G
1 hare6y oflirm thor I am exempt from ihe Controctor's Licanse ,
Law for 7he followinp rnnc�n($=tt{on 7Q3�,c, o;;;;�ess and Addinonoi S�an&a�rh f��cous ,1 ° 1 0 7 O O
Professions Code):� . . ,
Misc.Conduits 8 Conducrors
❑ I,as owner of rhe property,will do the work and�he . • • � �7��ci -
strudure is no1 imended or offered for sole(Section O�her(See Complete Fee Schedule)_
7044,Business and Prafesiions Code). , � �2� 7—$4 �
CONSTRUCTION LENOING AGENCY � � � � � �� - � �
I hereby efffrm�ha�theie is a conshuction lending agancy for
Ihe performonce of the work for which ihis permi�is issoed pERMIT FEE - (Sub-To�ol) Cl'/r SQ � � �
(Sec.3097,G�.C.�. -
S �To O n/� P�AN CHECNING fEE - � - _ . .. .
lender i Nome - � .
3 �������Z—' PERMIT ISSUING FEE � Q S� �
Lender'sAddress �-q Qf9�-/Y!� �-.f�'• � -
I cerfify fhat I have repd this opplication and s�ote thot�he TOTAL FEE �( ,�1 Q
above infamorion is torretl.I agree to comply wi�h oil Counry . �
ordinances and Stote lows regolaling Eledriml wiring,and . �
here6y auth resentalives of this CouNy 10 enter opon � - - � -� --� �
�he a n ty for in fion porposes. -
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