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HomeMy WebLinkAbout1349A (13) WORKERS'COMPENSATIONDECLARATION 76A663 10/81 APPLIGATION FOR ELECTRICAL PERMIT � � I hereby affirm Ihat I hove a cerliiicale of consent�o self CE-806(' insure,or a certificote of Workers'Compenso�ion Insuronce, � � COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy ihereof{Sec.3800,Lab.C.). � � �". . P❑oli[y KO,f' ,� . .�'� CompOny ' � FOR AVPUCANT i0 FILL IN JOB �� - . Certified copy is he�eby furnished. ' New Resideniial Bldgs.8 Pools EACH NO. FEE ADDRESS /�! .J•� ��Certif�ed copy is iiled wfth�he counry building inspec- -�'�a ZFamily,Sq.Fr:-� s — S LOCALITY � � tion departmenl. Multi-family�5q.ff. � — NEAREST . _ � . . CROSS ST. - Residenfiol Swimming Pools OWNER OR - Do�e � Applicpnt� . FIRM NAME ' , CERTIfICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Ltght_Sw._ ��� � COMPENSATION INSURANCE Ao�aESS � First 20 �(ihls secFion need no1 bs tomplelad i(tha work involvad by To�al No. Addi�ionol CIN Tel.No. - � - tho parmil(�for one hundrod dollar�(5100)er less.) PIAN CHECK I certiiy Ihot in ihe performance of the work for whith Ihis qDpLIC4NT permil is issved,I sholl not employ ony person in any monner � - so as to become svbjeU�o the Workers'Compensation laws. Lighting Fix�ores � First 20 A�ORE55� - Total No. �+dditional CITY Tel.No. � Dale . - .. , _ aPPlicant��,,' . _.'. _',.�-'....: NOTICE TO APPIICANT: If, aNer moking this Certifimte of Fi.ed Appliances Not Over 1 HP qpp�IIG4NT;-� ' � Exemption, you"should become subject to the Workers' Range_Heater_D.W._ - , Compensotion provisions of the lobor Code,you mus�for�h- Oven —Dryer _W.M.— ADDRESS r � with tomply with such provisions or this permit shall be 7op _FAU —W,H,— CITY� � y.Tel.No. - deamed revoked. Hood _Fan _Olher_ . ,.',..- '-� � � - LICENSED COMRACTORS DECLARATION LIC�NSE OR . - I hereby aNirm ihat I am licensed under provisions of Chopter 9 Disp. _Room Air Cond. — REG.NUMBER�. Cioss( } (commencing with Sec�ion 7000)of Division 3 of the Business � DISTRICT NO. PROCESSED BY a � and Professions Code,and my license is in full force and eNett. Po''�er Apparalus 8 Large Applionces � - � Size 8 Type HP,KW,KVA,or KVAR V License'Nomber�::'�� � '�� � lic•Class � - FINAL � . Up to 1 Incl. DATE — - Over 1 fo 10 Incl. YALIDATION � Contractor3�� . .� Date Over 10 to SO Incl. . � } ❑ .�.. . .�:.. '. ._ FINAL � I am exempl under Set. Over 50 l0 100 Inc. BY � " - B.BP.C.for�his reason Over 100 Q Sarvices,Swbd.,MCC 8 Panelboards a Date: 0-2W Amp.Under 600 V , ' � w � Signature 201•1000 Amp.Under 600 V � . ❑ Over 1000 Amp.or Over 600 V E.emption for Reg.Moint EIeU. - SINGLE FAMILY Tnmp.Power Pole 8 Appurtenantes .:;,1,,'t i4�'j; HOME OWNER-BUILDER DECLARATION S�y�with One B�onch Cirmit - - �:�r,���.si;s�. I here6y affirm that I om exempt irom�he ContraUor's license Addirional Sign Branch Cirtuih � � law ior�he following roncon(Src�ion 7031.5, Aotinnss nnd :'"�:��' �c-' Prafessions Code): � ���•����� {""��� � Misc.Conduits 8 Condudors "'_;��-"�'�- I,os owner oi Ihe property,will do Ihe work and the "�°:�'!��ii�'t?: structure is�nol iNended or offered ior sole(SeUion Other(See Complete Fee Schedule)_ ► , `„„r , . 7D44,BusinessandProfessionsCode). ' ;�.l�,l:>>;';�'�?� CONSTRUCTION LENDING AGENCY � . I hereby a(firm fhat}heie is a Construdion lending agency for the periormance of ihe work for which this permit is issued PERMIT FEE (Sub-Total) (Set.3097,Civ.C.J. � PLAN CHECKING FEE - � ' Lender's Name - � PERMIT ISSUING FEE � � � Lender's Address � I certify�hat I have read this opplicotion and s�ate thol the TOTAL FEE .1 above informarion is correct.I ogrea lo comply wi�h all Covnty , o�dinances and Slale lows reguloting Electricol wiring,ond � � � , hereby authorize rep�esenlative5 of this County to enter upon the above-mentioned properiy ior inspec�ion purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE �_� , "'Signatura of Petminee _ • � Da�e � - �-- - �,.... � �..�.._i._ � .. ..'. _�... _ .._I. ._.i_ __._ f ` - ' i , i { i '�-- � I ,� V� � , � � � � ' ��� � , ' � � j j I � � � ` I . ;;' � � � ; ; i I • ; � ' �: � , i I I I I I � ' I� � � i i : ic ; I I : - � ! i i � i ; i I '� _ j � � _ , ;. � i � . � I i �. i .. i�-- -----� ..---' I � I �, � . j I _ � I ' �' . � • I . 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