HomeMy WebLinkAbout1696A (17) 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 topy is hereb fumiShed. EACH NO. �� FEE +aDRES. ((
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 Atltlitional-
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
Ezemptioq ypu should 6ecome subject to the Workers'CompensaFan 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.
:} 6�.�:l� �
� .. .. _ . . _.. . . . . . Services,Swbd.,MCC 8 Panelboards - � ► � ��� - Z
� Date: � 0-200 Amp.Under 6D0 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: `—\7�—
� ❑ 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 (� � � ��-- � � ��
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
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