HomeMy WebLinkAbout1728A (17) WORKER$"COMPENSATIONDECIARATION 76A663 10iB1 APPLICATION FOR ELECTRICAL PERMIT � �
I hereby offirm thal I ha�e a cenificaie ol consent to self CE�806G .
insure,or a certificate o4 Workers'Compensoi�on Insuronce, COUNTY OF LOS ANGELES BUIIDING AND SAFETY
or a cerlified copy Ihereof�Sec,3800,Lab.C.) Y -
P❑olicy No. 3•�b7�Company S'�'y�G�l�U+�N FOR A►►LICANT TO Flll IN JOB r
Certilied copy is hereby furnished. New Res�deniiol Bldgs.8 Pools EnCH NO. FFE AooRE55 -�G 7 �� 2� .��
� Ceniiied copy is filed with the counry building inspec- � 1 8 2-Family,Sq.Ft. 5 — S LOCALITY �� �
tion deparlment. Multi-iamily Sq.Ft. — rIEnREST
Retidenliai5wimmin Poos CROSSST, S;JWS , � )SS„
Do1e a1-$-��Applicont �j��('rl r OWNER OR • ( j /*� �
� FIRM NAME p+ / (��, /
CERTIFICATE OF EXEMPTION FROM WORKERS' p� mnu �
COMPENSATION INSURANCE Outlets:Rec�light_Sw._L_ `� � ADDRESS6 '�OIJ /� �
(Thl�tocFlon nesd nof b�complN�d if th�work involv�d by Firsf 20
fh�permif is for one hundrad dollars(f100�or les�.) Total No. �� Additional � CI7Y /� Tel.No.=/3 G�y'�js
I cer�ify lhat in the performance oF Ihe work for which Ihis APMICANTK
permit is issued,I sholl no1 e�p loy any person in ony manner
so as to become subjecl�o the Workers'Campensation Laws. Ligh�ing Fiatures First 20 ���SQ ADDRE55 �
To�al No.� Addilionol
/� i�' CITY • Tel.No.
pote ..�.b_Appliwnt��l�L Fixed Appliances No�Over 1 HP PERMIT �
NOTICE TO APPUCANT: If, oi�er mok�ng this Certificme of R�PLICANT � 3'/ ���' {/'�� �
Exempiion, you should hecome subject to the Workeri Range�Heater_D.W._
Compensotion provisions of the Labor Code,you m�st forth- Oven �Dryer _W.M._ ADDRESS ,v� y7�
with comply wi1M1 su�h provisions or Ihis permil shall be Top _FAU —W.H..L
deemed revoked. � Hood _Fan _Olher_ CITY , �� Cy�, al.No.5 S
LICENSED CONTRACTORS DECLARATION � uCEnISE OR
I hereby affirm Ihot I am licensed under provisions of Chopler 9 �Disp. _Room Air Cond. — REG.NUMBER �{ �7Js Closs.[—(d �
(mmmencing with SeUion 7000)of�ivision 3 oi the Business power Apporatus 8 large Appiiances � � �-� - DISTRICT NO... .. . .. PROCES Y� n-� -
� and Professions Code,and my litense is in full farce ond effect. f� U
ySG 3J(� Size Type HP,KW,KVA,or KVAR V
license Number / Lic.Closs ���b FINAL , �
Up to 1 Ind. �
' I./y,f._��/ ��� �_ Over 1 ro 10 Incl. DATE [�C�� 4� VALIDATION V
CoNroUor �Da�e Over 10 to 50 Ind. `
❑ FINAL W
I om e:empt under Set. Over 50 to 100 Inc. B „'f� a
B.BP.C.for�hiz reason �ef�� vJ� Z ��
. Services,Swbd.,MCC 8 Panelboards � �
DO}e' 0-200 Amp.Under 600 V .'�-. . .
Signature 201-1000 Amp.Under 6W V �
aOver 1000 Amp.or Over 60p V
EKemplion for Reg.Moint.Elet�.
SINGLE FAMILY Temp.Power Pole 8 Appvrlenances
HOME OWNER-BUIIDER�ECIARATION Sign with One Branth Circui� $ s
1 hereby offirm thot I am eRempt from the Contractor's ticense Aedirional Sign Branch Circuits � 4 1 �i 2 8 A
Law tor the following reoson(Sec�ion 7D31.5, Business and
Professlons Code): �
❑ �t. • • ••�
I,as owner of tha property,will do ihe work and the M:sc.Condui�s 8 Conduc�ors
sir�c�ure is no1 intended or offered for sole(Settion Other($ee Complele Fee Schedule)_ , r •�3 ri B 5 0
7044,Business and Professions Code). . • •3 4 8 5 0 c=i.
CONSTRUCTION 1EN01NG AGENCY
I hereby aFFirm thal lhere is o conslruclion lending agenty for • Q 9�g..$6
fhe perfo�mance of the work far which ihis permit is issued PERMIT FEE - (Sub•Totol)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE � "
Lender'S Nome �
PERMIT ISSUING FEE 1Q �
lender's Addrezs �,I
I certify iha�I have read this application ond sro�e Ihal ihe TOTAI FEE t•�
obove information is mrred.I agree fo tomply wiih all Coon�y
o�dinonces ond State lows�egula�ing Eleclricol wiring,and . ,
hereby au�ho�ize represenratives of this County�o enier upon
the obove-menrtoned properry for inspection pu�poses. SEE REVERSE POR EXPLANATORY LANGUAGE
' r'j"��.6
Signoture Cf Permitt e , Date
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