HomeMy WebLinkAbout1599A (17) WORKERS'COMPENSATION DECtARAT10N I� 76A663 �0/el ���r I
� I hereby offirm that 1 have a certiTicole of consent to seff � �E-� APPLICATION FOR ELECTRICAL PERMIT /� � _
insure,or a certifitare of Workers'Compensotion Insvrance, � COUNTY OF�OS ANGELES BUILDING AND$AFETY �/^
or o certif�ed topy�hereoi(Sec.3800,Lob.C.) . �
P�olicy No. Company - FOR APPLIGM TO FlLt IN qppRE55 � O S / N L�Q. �
Cerlified copy is hereby iornished. , � New Residentiol Bldgs.8 Pools . EACH NO. FEE
. � 1 8 2.Famil Ft. � s — S IOCALITY Q N A
Cerlified topy is filad with rhe county building inspet- Y.S9•
lion deparlmenL � � Multi-fomily Sq.F: �� � — NEnREST
Residenliol Swimining Pools
�R�sT. ,e a e�vu
Date Applitant � ' �RMENq�L e�/ CNT �
CERTIfICATE OF EXEMPTION FROM WORKERS' Oullefs:Rec Light,�Sw...�. B.S. L %/G L✓.Q
COMPENSATION INSURANCE First lU p /+DD�RE55
(Thi�s�dion n��d net b�tompl�hd if Ih�work fnrolv�d by n .
tha parmif h for ono hundrod dellars(5100)or Iws.) Total No.�_� Additional � ��N 0 Je Tal.No.
PIAN CHECK
I certify Ihot in ihe performonte of�he work for whlch lhis APPLICAN7
permit is issued,I shall not emplpy any person,in any rnonner
so as fo become subject to the Workers'Compenw�ion Laws. l�9hting Fixturez First ZO ADDRESS
Tolal No.�� Addilional
Datea PP���a��.?��FELeci�ia CITY � Tel.No.
NOTIC TO PPLICANT: If, affer moking ihis Certificate of Fixad Appliances Not Over 1 HP PERMii /� :
Exemplion, yau shovid become s�bject to �he Workeri Range_Heater_D.W._ A���NT � G� G G .
Compenwtion�provisions oF the Lobor Code,you�must forih- Oven _D�yer _W.M. ADORE55 �� � �� � C .
with tomply with such provizions or �his permit sholl be Top _FAU. —W.H.� _�A6
deemed revoked. Hood _Fan _Oiher_ CITY Tel.No. ���.y
UCENSED CONTRACTORS DECLARATION � OO LtCENSE OR �
I hereby offirm thot 1 om licensed�nder provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBEtt ,s � - Closs,e '
(cornmencing with Section 7000)of Division 3 oF rhe Bus�ness power Apparatus 8 Lorge Applionces DISTRICT NO. ' PROCESS�p BY �,
ond Proiessions Code,ond my license is in full force ond effett �O ,( . t� �
��p-f Size&Type HP,KW,KVA,or KVAR� ,/ ,�f�Q� �
License Number � -��'�7aS Lia Class� -. f . Up to 1 Ind. . . . `t 0� FINAI � / . y .
''7� Q Over 1 to 10 Incl.�
Contrador��F EL l."�/�Qlrga�e �.� p . DATE �t /y� YAIIDATION � '
❑ Over IO l0 50 Incl. FINAI I� ~ .
I om eaempt onder Sec. Over 50 10 100 Inc, BY �` �'�y� . . , a .
- 8.8P.C.for this reason Over 100 . � - Z
� Do�e• - Sarvi MCC 8 Panelboards - G� � � �_ ;
' 0•2W Am Under 600 V �.
SignaNre I-1000 Amp.Under 600 V - �
OOver 1000 Amp.or Over 600 V '
Ezemption for Reg.MainL Elect.
SINGLE FAMILY Temp.Power Pole 8 Appur�enances� - � -
HOME OWNER-BUILDER DECLARATION Sign with One 6ranch Circuit �
I heraby offirm rha�I om ezempt(rom�he Controcfor's License Add�!icr.cl Sign 9ren:h Circui`; �
law for Ine foliowing reason(Sec�ion 7031.5, Bvsiness and ��
Professions Code): � �� 5 9.9 A •
❑ I,as owner of the properry,will do�he work ond the Mizc.Condui�s 8 Conductors •��'. .
structure is no�iniended or offered for sole(Section Other(Sae Complete Fee Schedule)_ ► �� �� ,
704a,Business ond Professions Code). � • �5 9.7 5
� CONSTRUCTION LENOING AGENCY
f I hereby of(irm thot there is a tonstruction lending ogenq for •'• •5 9.7 5 c=.�
. the performonce of�he work for which this permit is issued PERMIT FEE � (Sub•To�al) � 7 .
. ISec.3097.Civ.C.�. . � � . . �� 7-B�l -
C PLAN CHECKING FEE
" Lender's Noma-`�4/�/T � N� - . � � .
�` J/ N�' v � ✓e pERMiT ISSUING FEE . . � Q �
� Lender's Address � - - �
- I certify�hot I have reod�his opplicoti ond srate that the TOTAL FEE ��, � �
obove informalion is mrrecr.I agree io mmply wiih all Counry . � �
�ardinonces ond$tote IawS regolo�ing EleUricol wiring,ond �
hereby ou�horize represeniatives of�lysto�nty to enter upon � � � � �
�o6ove•m i pro erty for'f( cuon pu�poses. - . , SEE REVERSE FOR EXPtANATORY LANGUAGE
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