HomeMy WebLinkAbout1686A WORKERS'COMPENSATION DECLARATION ��`� �o�B1 APPLICATION FOR ELECTRICAL PERMIT � ��
I here6y oHirm that I hove a cernficate of consant�o self �E'� �
insure,or a cerlificote of Workers'Compensation Insurance, �OUNTY OF LOS ANGELES BUILDING AND SAFETY
o�a cerfified copy fhe�eof(Sec.3800,�Lab.C.) .
a[y No. Company FOR APRICAM TO Flll IN DDRE55 rI�/Y7/R1D qI�IQ
Carlified copy is hereby furnished. New Rasidenlial Bidgs.8 Pools EACH NO. FEE
� 1 8�-Famil Ft. s — E LOCALITY �,L/
Cer�ified copy is filed with the county building inspeo- Y.59•
tion deparlmenf. � Multi-family Sq.Ft. — NEAREST
� Residentiol 5wimming Pools � CRO555T.
OWNfR OR
, Date Appliwnf . . FIRM NAME �1 A1 ✓'
' CERTIFICATE OF E%EMPTION FROM WORKERS' putlels:Rec�light_$w,_ �"'"�� -
GOMPENSATION INSURANCE � �d First 40� �ADDRE55 -
(Th�s�eeTlon nesd no1 bs complafed if fha work inrolr�d by 7o�al No:�.H�. Additional CITY � ' Tel.No.
fha parmit is for on�hundrod dollan(SI00)or lass.) � .
I cerlify thaf in the perFormance of�he work for which Ihis . � . � APMICANT� �
� permit is issued,I shall no�amploy a�y perso�in ony monner �
so as to become subject ro ihe Workers'Compensation Laws. Li9hting Fixtures . Fint 20 ADDRESS
Total No. Addilionol
�k CITY Tel.No.
Dote /7•2Z-AS�Applicont '. • � Fiaed Appliantes Not Ovar 1 HP PERMiT
NOTICE TO APPLICANT: If, afrer mokin �his Cert icote of APPLIfANi LL� /S�H/f�1
Ezemption, yau should become subject 10-1he Wo�kers' Range_Healer_D.W._
Compensotton provlsions of the lobor Code,you must forih- Oven _Dryer —W.M._ ADDRESS ��� _ ��NO.J�
wi�h comply 'Ih s�ch provisions or Ihis pe�mit sholl be Tap _FAU —�N.H.—
deemed revoked. - � Hood _Fan _Oiher_ � CIN � Tel.No.`�5�3�/3
LICENSED CONTRACTORS DECLARATION lK'�NSe OR •
1 hereby affirm ihot I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER Q Clou. $ -
(commencing with Section 7000)of Division 3 of the B�siness � DISTRICT NO. PROCE D BY
and Prolesscons Code,and m license is in foll Force ond eHecf. �ower Apporolus 8 Lorge Appliances . >
Lfi[� Y �'( Size 8 Type HP,KW,KVA,or KVAR- �O 0
Licanse Number �T" 77�' Lia Ciass ^' UP�o����� � FINAL ( -- - V
�1 �I ,Z,t S� over 1 to lo Inci. �
Coniiacto��y lvl�'9/➢re0�'pate � � DATE � ��1�1r/ VAU�ATIOH �
ld`�
❑ —����— Over 10 to 50 Incl. FINAL - ~ ,
1 am ezempt onde�Set. Over 50 to 100 Inc. BY . � ,
8.8P.C.ior this reoson .Over 100 �— w
Serviros,Swbd.,MCC B Panelboards � ► � � �� � Z
Dele: 0-Z00 Amp.Under 600 V
Signoture � �a"'4n-�+*� 201-1000 Amp.Under 600 V
aOver 1000 Amp.or Over 600 V � . .
E.empiion for Reg.Moint.Elen.
SINGLE FAMILY Temp.Power Pole 8 Appurtenonces
HOME OWNER-BUILDER DECLARATION Sign wi�h�One Bronch Circuil
I hereby affirm tho�I vm exempl from ihe Contro[1or's Litense Additional Sign Branch Circuits
Lnw for thr fnllnwin�rPnsnn{Sec�inn 7031.5, Bos��?ss and . � -
Professions Code): �� b�,6 A ,
❑ I,as owner of fhe properly,will do Ihe work ond the Misc.Conduils 8 Conductors � - � � �
strocture is not iNended or offered for sale(Sec�ion Orher(See Complate Fee Schedvle)_ ► �� • • • •2
7044,Business and Professions Code). � • �4 9,5 0
CONSTRUCTION LENDING AGENCY � � . . .
I hereby affirm tho�there is a construttion lending agency for • • •4 9,5 0 c=i
rhe performonce af ihe work for which this permit is issued PERMIT FEE - (Sub•To�al) �C' d , �-- ' ' . • .
(Sec.3ov�,ei�.e.). 0 2 2 2—8 4
PLAN CHECKING FEE � � . .
Lender i Name � �"�
PERMIT ISSUING FEE , Q (/ ,
Lender's Address
I certi(y thot I have reod this opplicotion ond s�ate that rhe TOTAL FEE SCJ �
obove iniormafion is correcl.I agree 10 comply wilh all Counly
ordinonces and$ta�e laws regulo�ing Electrical wiring,ond - � �
hereby authorize representatives of this Coonty to enter upon � - �
�he obove-mention property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
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