HomeMy WebLinkAbout1339A :�. WO�iRERS'COMPENSATION DECLARATION 76n66] �o�e� APPUCATION FOR ELECTRICAL PERMIT
TI hereby af(iim fhal I have o terlificole of consenl�o self CE-&MG �
insure,or a tertificate of Wo�kers'Compensation Insu�once, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a�r�iOe i copy�hereof(Sec.3800/,+Lab.C.) A 1 �
P❑ol��cyNo. ��'� Compony—l7CA�AI /'tCCi(i�h,` FORAYPIICANiTOFIILIN JOB /�� Z j��amOapL �Y $I•
Certified copy�s hereby furnizhed. New Residential Bldgs.8 Pools EACH NO. FEE ADDRE55 1(.(/(p ,Y
�Ce�tified copy is filed wilh�q�n1y¢ui ding i peo- 1 8 2-Family,Sq.Ft. S = S LOCALITY ���y,{t�0y�� ��
fion departmen�. / l MVlti-(Omily Sq.Ft. NEAREST
� � � Residential Swimming Pools cRoss sr. St- fo55 i n
Date U1 Applitan��� J OWNER OR
CER IFICATE OF EXEMPTION FROM WORKERS' �,8 � � FIRM NAME ��I
Ou�leis:Rec_Ligh� Sw._ � �"u`�� s UAf �Y
� COMPENSATION WSURANCE �"�S a0 ADDRESS
Thl���cNen nNd net b�com I�f�d IF th�werfc Involv�d b r First 20
� � Y Total No.S� Additional CITY �n Tel.No.
lhe parmil Is for ona hundrod dollors(SI00)or le�s.) ' vtarv cr+eCK /�� G
I ce�tify that in the periormante of the wo�k for which this APP�IC.4NT NK.V �a� l.�«�i L
permit is issued,I shall not employ any person in ony monner �
so as�o become subjec�to the Workers'Compensation laws. ti9hting Fixtures� First 40 '7� r ADDRESS S � vp_�I I �'ZQ�
- Total No.� Addirional 2
. GN (,,�, Tel.No. rj'1�2SI>
Da�e epplicont Fixed Appliances Not Over I HP PERMIT I
NOTICE TO APPLICANT: If, after making ihis Certificote of APMiCANT a E YL�yic.
E:empiion, you should betome svbject �o the Workers' Range_Heater_D.W._
Companso�ion provisions of the Labor Code,you must forth• Oven _Dryer _W.M.— ADDRESS S[�( val( l• � �
wiih comply wi�h such provisions or �his pe�mit sholl be Top _FAU —W.H.— �IiY L,�, el.No. ��25�
deemed revoked. . Hood _Fan _O�her—
.. LICENSED CONTRACTORS�ECtARATION UCENSE OR (���Q C—IO
I hereby offirm that I am licensed under provisions of Chapter9 Disp. _Room Air Cond. — REG.NUMBER u Class. �
� (commencing with Section 7000)of Division 3 of Ihe Business . D�STRICT NO. PROCESSED BY �,:
and Professions Code,and my license is in full force and effett. Power Apporotus 8 lorge Applionces� �
�J Q, 1 $ize&Type HP,KW,KVA,or KVAR� O U
License Number ✓"��v Lic.Class �—r� FINAL �
I� Up to 1 Ind.
Contractor �� [G�� �J'Z ('C�� = Over 1 to IOlncl. DATE p� VALIDATION �h
❑ Date Over 10 to 50 Intl. FIN L W
I am exempt under Sec. Over SO fo 100 Inc. BY �
8.8P.C.for ihis reason �vef�� z
Date: Services,Swbd.,MCC 8 Panelboards� �
0-2W Amp.Under 600 V , -
�ignature 401-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exempiion fo.Reg.Moint Elect. .q� 3�J.(�A
$INGLE FAMILY Temp.Power Pole 8 Appur�enances
HOME OWNER-BUILDER DEQARATION i��• • • ��
�hernl.y..f{�.�..il...� �t.�. }I.e�'..�y�.�.,.:i�.e�.e Sign with One Branch Circvil
�°�T���T�,„_� Additionol Sign 8ranch Circuits �
Low for fhe following reoson(Sectton 7031.5, Bosiness and I � 2 9.�Q
Profess�ons Code): �
❑ I,os owner oi the properly,will do Ihe work and 1he Misc.Conduils 8 Conducfors • • � 2 9.�Q u
srruaure is nor in�ended o�offered for sole(Seu�on Othe�(See Comple�e Fee Schedule)_ , ��� O B.P 7—S b �
7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY .
I hereby offirm that lhere is a construclion lending ogenty for
the periormance of Ihe work ior which ihis pe�mit is isi�ed pERMIT FEE ($ub-Totol) �
�Sec.3097,Civ.C.).
PLAN CNECKING FEE � �
Lender's Name
� PERMIT ISSUING FEE �O �
lender'sAddress �� �
I tertify Ihot I hove reod this applimlion ond stale that the TOTAt FEE �
ove�nlormot�on�s corred.I ogree�o comply wiih all Counry
or � nces and SI ws reguloting Elechicol wiring,and . .
hereb authoriz repr sentotives af this County to enler upon
ihe o6 e�men�ion proper'y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��`� d-Z'7-8�
a
�gnorure of Pe�minee �ate .
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