HomeMy WebLinkAbout1038A (9) WORKERS'COMPENSATION DECLARATION 76A667 IOiei � '
I hereby affirm thof I have a cerli(icale of�o�=e�,�a=e�f �E-� APPLICATION FOR ELECTRICAL PERMIT �
i�s�re,or a certificme of Worken'Compensation Insurante, COUNTY Of LOS ANGELES � BUILDING AND SAFETY
or a certified copy thereol(Sec 38070,Lab.C.) - � .
R y'`'s� l�-M� FOR APPLICANT TO flll IN �� �j / �1� J
P❑olicy No. Company . l� � /�
Ce�tified topy is hareby f�rnished. New Residenliol Bldgs.8 Pools EACH NO. FEE AODRESS �( - ��1 '�I� � `�
� �CertiFied topy is filed wiih ihe county building Inspec- I 8 2-Fomily,Sq.Ft. s — f LO�ALIT �i�,n�ti1 � ���,,�!� p,'aMov�
tiondeparimenf. - Mulfidamily5q.ft. — CBOSSST. 1 � O d8A1 S /Rs�� Y 1V
Date q ���an� Rasidentiol Swimming Poals OWNER OR �1
PP A' FIRM NAME pY D lhSD�
CERTIFICATE OF EXEMPTION�FROM WORKERS' '- Outlets:Ret�Li9heo�5w.� ��L t
COMPENSATION INSURANCE � � � ADoaE55 J rI �t�$�7 �RS
Thi���dion nead no1 b�com lefad if fh�woik imolv�d b Firsf 20
� P Y Total No.� Additional CITY��"Z f� i �Tel.No.
Ihs psrmif Is(or on�hundr�d dollars(f100)or I��f.)
I cerlify Ihot in the performance of Ihe work for�which Ihis _ __ qq�qHE�CK. . . _
permif is issued,I shali not employ ony person in any manner
so as lo became subject to the Workars'Compensafion Laws. Li9hting Fixtur�es C� Fiisl 20 �AD�RES$
� � To�ol No._L= Addilional CITY � Tel.No. ,
Date Applicant � Fized Applionces No1 Over I HP PERMIT
NOTICE TO APPIICANT: If, ofler moking this Certificale of qpa��M � %L
Exemption, you should become subjett�lo fhe Woikerx' Ronge_Heater_D.W.�
Compensation provisions of the Lobor Code,you must forih- Oven _�ryer _W.M.— ADDRE55 ��Ly �}, �1�c� '
wi�h comply with such provisions or this permit shall be Top .—.FAU W.H.—
deemed revoked. - .� � � - CITY � 1 -��C{ � Ta�.No. �J-� 5 _
Hood _Fan Other_
LICENSED CON7RACTORS DECLARATION uCENSE O IJ
I hereby afiirm rho�I om licensed under provisions ot Chaprer 9 . � Disp. _Room Air Cond. — aEG.NUMeEa ��Y � Z� -- - . Class. C�
(commencing wirh Sec�ion 7000)of Division 3 of the Businezs DISTRIC7 NO. FROCESS BY }
and Profezsions Gode,and my license is in full force ond effect. � Power Apporarus 8 Large Applionces . _ ____ �
'I I�/ Size 8 Type HP,KW,KVA,or KVAR� �O �
License Number�� �`"�( ` � lia Closs � �U Up to 1 Incl. � - FINAL � ���� �� � �- V
1'3 �Date /- / 'L�--�-t�Over I to IO lncl. ! DA7E `,�t.�� VAIIDATION �
Confraclor ! G�� ��L�/� ��_� Over 10 to 50 Ind. � O
OFINAL ~
I om ezempt under�Set. Over 50 fo 100 Inc. BY 1rI a
B.BP.C.for this reason Over 100 °�`�� -t^'�' 2
� � Do� � Services,Swbd.,MCC&Panelboards � 'y � � � � � � � �-
0-200 Amp.Under bp0 V �
$'��„�ma�- p � 201-1000 Amp.Under 600 V � / .- ....
❑ • � Over 1000 Amp.or Over 600 V ' �
Exemption{or Reg.Moinl.Elec1.
�
SINGLE FAMILY Temp.Power Pole 8 Appurfenances �
HOME OWNER-BUILDER DECIARATION 5�9�,,Vilh One Bronch C�rcuit z� O�8 A
I hereby affirm thot I am exempr from ihe Comracror's license Addi��onol Sign Branch Circuirs
Law for the(ollowina reason f5ection 7031.5,BusinPes o�d . #• • • • •�
Professions Code): � �
❑ I,as owner af the property,will do ihe wark and�he Mrsa Conduits 8 Conductors � - � •3 4 7,5 0
shuc�ure is no�intended or ofiered for sale(Sedion Other(See Complere Fee Schedule)_ , _
7044,Business ond Professions Code). , •'.�J Lt%.J�O c�
CONSTRUCTION IENDING AGENCY � Q�,-��3-�8 4 -
I hereby affirm tha��here is a construc�ion lending ogency for � �
�he performonce of Ihe work�or which Ihis permit is issued PERMIT FEE (Sub-To�otJ � �� � � . _ . -. ...
(Sea 3W7,Civ.C.).
PLAN CHECKING FEE - � - _. . ..
Lender's Nome � �
PERMIi ISSUING FEE � a O . ., _ __ '
lendei s Address �
I ce�tify that I have reod this opplication and s�me tha�the . TOTAL FEE ,3��f,s� ,
above informofian is correcL I agree lo comply with oll Coumy _ � .
ordfnances and S�a�e laws reguloting Electriml wiring,and . �
hereby auihorize represeNotives of lhis County�o enter upon � - � �
tbe ove- e bn p� erly f inspedion purposes._
J ,, SEE REVERSE FOR EXiIANATORY LANGUAGE
//3 —�,.
Signalu e of Permittee Dale
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