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HomeMy WebLinkAbout1696A WORKERS'COMPENSATION DECLARATION 76A663 ioie� ` I hereby aifirm that I have a certiFicate oF consent ro seil�nsure, CE•eog� APPUCATION FOR ELECTRICAL PE MIT 8 � � or a cert�fcate of Workcrs'Compensatron Insurance,or a tertilied COUNTY OF LOS ANGELES BU1LD G D SAFETY � copy thereof(Sec.3800.Lab.C.) � � Po�iCy No. � � �pmp3�y� FOR APpLICANT TO FILL IN ' JOo � ❑ Certitied copy is hereb fumished. EACH N0. �� FEE �DRES. (� Y � � New Residential Bldgs.&Pools LOCALITY .� � i 1 R 2-FamilY.Sq.Ft. � — S C2ftified COpy is lied with Ihe cWnty bUi�tling in5pec1i0n NEMEST department � � Mul[i-0amily Sq.Ft. . . CROSS SL � � Residential Swimming Poois , OwNER OH Date pppliC�nf 'l 1� �I FlqM NAM11E � �CERTIfICATE OF EXEMPTION FROM 4VORKERS' '� p�Nets Rec-// Light r-� Sw.r� ��� ��OI �� �if �. � . COMPENSATION INSURANCE ' ' F���20 � � �� �p AODRESS (Thts aectbn need not be compieted R the wak Involved by the f/�r, � � CITY (��Tel. r �� � permit Is Iw one hundred dollaro($100�or IeasJ Total No.��r Additional- I CBfti(y that Irl thC pCr(OlfnanCC of ihC wOrk f0�whiCh 1hi3 pCfmi� '. . .. _. PLAN CHECK � / D-. Is issued,I shali not em lo a I �'��`�'1T R��•• C! p y rcy person in arry manner so as to 1n I Y�� Q � become subject to Ihe Workers'Compensation Laws. � . L'ghtirg Fixtme9 Frst 20 � 4'�V A�DRESS ��� Additional � �� //�1 � - Total No.� CRY 7el Date APPi�Cant . . . F.Ld APPtianCe9 Not Over 1 HP ���� `� -r f NOTICE TO APPLICANT: If, after making this Certifica!e of PERMIT Exemption,you should become subject to the Workers'Compensa['an Range_ Heater_O.W. . ����'rT �provisions of the Labor Code,you must forthwith compiy with such Oven_�ryer_ W.M._ ADORESS � � •provisions or Ihis permit shall be deemed rewked. � Top _FAU _ NJH.� - � . _ . _. . _ .. �- GTY Tel.No. � LICENSED CONTF7ACTORS DECLARATION Hood_Fan _Other_ ��I hereby affirm that I am liCensed urber provisrons of Chsp}er 9 ucENSE OR . _ . . (commencing with Section 7000)oF Division 3 ot the Business and Disp. _Room Aif COM. _ REG.NUMBER Gass. Protessions Code,and my license is in fuil Forco aM effect. � aSmici NO. rraoCe55e�ev Power Apparatus 8 Large Appliances � . . . }: . �'� � p n. � Size.8Jype HP,I(W,KUA or KVAR Q Litense Number Lic.Class j Nf' Up to 1 Incl. •� � FINAL « Over 1 to 101nc1. DATE . � � �� � ... VAIIDATION Contractor -� � - Dzte � � " � Over 10 to SO InCI, fINAL _Q.._I am exempt under Sec. - Over 50 to 100 Inc. gy .. .. . . . . w �.BP.C.for this reason Over 100 ' G. � _ �� b�,.�;� � Services,Swbd.,MCC 8 Panelboards - Z � Date: � 0-200 Amp.Under 600 V � �� e � ► Si9natu�e 201-1000 Amp.Under 600 V � #� � 0 � 1 ^ i ❑ . �� O�.cr 7000 Amp.or O✓er 600 V i � o G(��;-.,� Exemption for Reg.Maint.Elect. � i � � SINGLE FAMILY �- - ..Temp.Power Pole 8 Appurten2nces � • "L�'(i::i)u HOME OWNER-BUILOER DECLARATION Si9n with One Branch Cirtuit � � I hereby alfirm th�[1 am exempt from the ContraCtors License Law � �Q.��—�:� � for the foliowing reason(SeCtion 7031.5,Business and RofessiDns AddiCronal Si�n BrarKh Circvits -- � ,..� (��i �--� / Codel: `\� � ❑ I,as owner of the property,will do the work and the structure Misc.Conduifs 8 Conductors - ��� S`� � i s n o t i n t e n d e d o r o f f e r e d f o r s al e(S e c t a n 7 0 4 4,B u si n e s s m�r(See Comp�ete Fee ScheduleJ_ , and Professions Code). , - CONSTRUCTION LENDING AGENCV - /� - , I hereby affirm that there is a construction lending agency for the `� pertormance of the work for which this permit is issued 1Sec.3097, � pERMIT FEE - � � �(Sub-To p (xf � � ��-- � � �� Civ.C.1. y � PLAN CHECKING FEE�,�Q% �m/�+ a � -'"' " � ' � Lender's Name . � PERMR ISSUING FEE - - � Q ... � .. . . . Lender's Address � I certity that I have read this application and state that the a6ove TOTAL FEE. _... ... ... . _ .. �� . , information is correct.I agree to comply with all Cwnty ordinances and State laws rc9uiating Eietlrical wiring,and hemby authorize . . . .. __ . . . .... . . . � i representatives of this Counry to enter upon the above-mentioned • - � property for inspeclion purposes. � SEE REYERSE FOR EXPLANATORY LANGUAGE -- � . . . . I � Signature of Permittee Date I .;��') Iv • �_ ' . ....C._..."' ". . . . l+_ ' -l.( ;� -��� ..- .'. i...,J..'.,_..��I�. _ _�l= _.�.__.�I��.'f ' � i I � I/. 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