HomeMy WebLinkAbout1635A (15) � WORKERS'.000.1PENSATiONDECLARATTON �6A663 � APPUCATION FOR ��.ECTRICAL PERMIT � �-� ��
CESO6G 12�801
1 hereny aftirm that I have a ceruficate ot consent to selt COUNTY OF LOS ANGELES �� � � BUILDING AND SAFETY
insure,or a certiflcate o(Workers'Compensatlon[nsurance,or . � � �
a cettified copy thereot(Sec.3800,Lab.CJ,
YV1���� FOR APPLICANT TO FILL IN. JOB
� Yol�ompany�..L-{CLL1u��j EACH NO. FEE AD�RESS '
/ New Residential Bldgs.&Poots
Q Cerlified c�py is hereby furnished. 1&2-Family,Sq.Ft. $ — $ LOCALITY ' .
� ' � Multi•family Sq.Ft. — NEAR T �
Certitied copy is filed with the county building inspection CROSS ST
department: . Residential Swimming Pools OWNER OR
� �� �.��' .� �� . � FIRM NAME
Date Applican 1 ���'1 ��_ Outlets:Rer�Light_Sw._ MAIL � -
Fir5t�20 FlDDRESS Q./1��
CER7IFICATE OF EXEh1PTION FROM WORKERS' Totat No.� Additionat CI7Y No. �
. COh1PGNSATION WSURANCE - PLAN CHECK � }
a
(This section need not be completed if the work involved APPLICANT � Q
by the permit is for one hundred dollazs (SI00)oc less.) Lighting Fixtures First 20 � qooRess
Total No.�_ Additionel �
1 certity that in Ihe performance ot the work for�vhich this Fixed Appliaaces Not Over 1 HP C�7Y Tel No. O
- permit is issued,I shall not employ any pvson in any manner PERMIT �
. so as to M1ecome subject to the Workers'Compensation Laws. Range_Heater_D.W. APPUCANT W
Oven _Dryer_W.M._ ADDRESS �
Date Applicant ' Top _FAU _W.H:._ Z
Hood_Fan _Qther_ CITY 7eINo
N07ICE TO APPLICANT:If,after making this Certificate of Oisp. _Room Air Cond._ IICENSE OR C�O -
lixemption, you should become suM1ject to the Workers' REG.NUM6ER Class
Compensation provisions of the Labor Code,you must forth- power Apparatus&Large Applianees DISTRICT NO. PROCESSED BV _ �
with comply with such provisions or this�permit shatl be Size&Type HP,KW,KVA,or KVAR � � � �� '
deemed revnked. � - Q (��,c,rit/ �
; , Upt01 Incl. FINAL � �
Over 1 to 101nc1, oATE ./ �I� VALIDATION
LICENSED CONTRACTORS DECLARATION Over 70 to 50 Incl. �
I hereby affirm[hat f am licensed under provisions oC Chapter Over 50 to 100 inc. F�NAL
9(commencing with Section 7000)of Division 3 of ihe Husi- Over 100 - BY � �
ness and F'rnfessions Code,and my license is in full force and .
eftecL � . Services ' � - � � .
License Numb- Lic.Class �j'1 6 0-200 Amp.Under 600 V
� / , 201-1000 Amp.Under 600 V . .
Comra t (I���/����{�� Over 1000 Amp,or Over 600 V •
H0�1E O\VNER•BUILDER DECLARATTON Temp.Powe�Pole&Appurtenances � �� b 3,�J� � '
I here6y affirm thaY I am exemp[ from ihe Contractor's Sign with One Brench Cireuit #� �2 j
....,..�c La:�fo:ihc fc1:o:::ng r.asca (5:...,... ...33.', P,us3- Additional Sign Branch Circuits . � . � � - ,
ness and Prntessinns Code): , � � • •� Q(�p
� Misc.Conduits&Canductors �
� 1;as o�Jner of the property,will da the work and the Other(See Complete Fee Schedulel— � •-• •�� Q�y Q� '
structure is not intended nr offered for sala (Section
�oaa,Ausiness and Pmfessions Code). C Z Z 3.—8 2
CONSTRUCTION LEND[NG AUENCY ,
� I hereby affirm tha� there is a construction lending agency � � �
for the performance ot the work tor which this permit is pERMIT FEE (Sub-Tota1) J
issued(Sec.JD97,Civ.C.). ' . . /
Lender's Name PLAN CHECKING FEE (One•Fourth Permit Fee) /
Lendei s Address PERMIT�SSUING�FEE
��
I certify that I have re�d this application and state that the TOTAL PEE � - � . \
abnve information is correcL I agrce to comply with all County . \
ordinances and Sta�e laws regula�ing Eiectrical wiring, and � �,r����'� \
hereby outhorize representatives of this County to encer upon Y '
the ahove- ntioned property tor inspection purposes. SEE'REVERSE POR EXPLANATORY LANGUAG6", �
�� ��
Signature of ermittee Uate ,
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