HomeMy WebLinkAbout0953A (5) WORKER$'COMPENSATIONDECIARATION I 76A663 �o,a, APPLICATION FOR�ELECTRICAL PERMIT
I hereby affirm thot I have a certificote of consenl ro sell � CE-806G � '
insure,or o certilicate of Workers'Compensalion Insurance, �OUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cerFlfled y there f Set.3800:La C. -
�(a%-t�l�#��t��5 -�i9rC Co P �6
P❑o�licy No. Compony �L/4. �d[j(� WR AYPLIUM TO Flll IN D�RES$ `�N� /7 �i I� :
C rtified copy is hereby furnished. New Residentiol Bldgs.8 Pools EACH NO. FEE
I 8 2-Fomil IOCALIN
Cer�itied copy is filed with the county boilding inspec- �' Y.�•F�• s — f n
lion deportment. Multi-family Sq.FI. — NEAREST . - � .
� Residenliol Swimming Pools GRO55 5T.
Dole_���-3:.�APPlicanl ��' OWNERpR �
� . , � 9 �-,� �� FIRM NAME—
CERTIFICATE OF EXEMPTIO FROM WORKERS' Outlets:Re Li htsL 5 MAIL
COMPENSATION NSURANCE Firs(20 � AD�RE55 � D
(Thb��clton n��d net 6�eomp4fsd i(}h�work Involrad b� Total No./�6 CITY Tel.No.
�I Ih�parmit I�lor ons h�ndnd dellan(5100)or Ie�sJ � Addiiionol /� P
I cer�ify that in ihe performonce of the work for which this FLANCHKK
permil is issued,I sholl not employ any person in any monner - . APRICANT
so os to become subjed to the Workers'Compenwlion taws. Li9hting Fiatvres / Firs1 20 � ADDRESS �
- � Tolol No. ( Addi�ional � .
3�v CITY Tel.No. .
Dole_ Appiicant ' Fized Applionces Not Over I HP PERMIT
NOTICE TO APPLICANi: If, after moking this Certiiico�e of APPL�CANT � � �
Eaemption, you should become subjeU to the�Workeri Ra�9e_Heoter_D.W._ -
I Compensotion provisions of the labo�Code,you musl forth- Ovan _Oryer —W.M._ . A�DRE � ��� � - �'��F� � �
with comply with such provislons or this permit shall 6e Top _FAU _W.H._
deemed revokad. CI - �o � �Tel.No i�'d •
IICENSEO CONTRACiORS DECLARATION Hood �Fan _Other_
I� �is _Room Air Cond. — uCENse oR �,
� I hereby oH�rm ihot 1 om lieensed under pro�is�ons ot Chapter 9 P� . REG.NUMBER p?f(���3 Claaa.0 ��
(commencing wi�h Sect�on 7000)o(Division 3 of the 6usiness powe�Apparalus 8 Lorge Applipnces . �ISTRICT NO. PROCES 8Y �,
i and Profeu�ons Code,and my license is in ioll force ond affect. �O - � d
� . �Size 8 Type HP,KW,KVA,or KVAR� q O �
� litense Number �Lic,Ciosa� � U l0 1 IncL FINAL a � V �
P
� �a' � Over 1 to IO lncl. DATE a O'/�� VALIDATION �
Controcro �o�e � a . �
Over 10 ro 50 Incl. FINAL . ~
❑ I a eaempt�nder Set. Over 50 to 100 Inc. BY h2L����— . d
0.8P.C.Ior this reason� -' O�er 100 vi
. � $ervices;Swbd.�'MCC 8 Panelboards � ► � � � � � �� � ��� Z
' Date: 0-�(10 Amp.Under 600 V -
SignaWre � 201-1000 Amp.Under 600 V � � � �� � �
❑ - . O�ver 1000 Amp.or Ovar 600 V .
Exemption for Re.g.Moint Elect. -
S�NGLE FAMILY Temp.Powar Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION � � � -" " � �'�O g'S.3 A�
Sign with One Branch Circuil � �
I hereby affirm that I om ezempt from�he Contracror's litense � �, . • . • �'�
�aw for Ihe following reoson�Section 7031.5, Business and Ari�1'�'^^^�Sinn Rrnnrh Cirtuits . .
Professions Code): � � •� �� 5 p
� � Misc.Condoits 8 Conducrors � _ �
I,os owner of the properly,will do the work ond the • �� ��.5 p�
sirudure is not intended or offered foi sale�SeUion 01her($ee Completa Fee Schedule)_ ► - �
� 7044,Business ond Proiessions Code�. Q,�.j Q'8�l
CONS7RUCTION IENDING AGENCY' � � � -�
I hereby affirm that there is a construciion lend�ng agenry for � .
�he performonce of�he work for which this permit is issued � PERMIT PEE �- (Sub•iotal� 6 � - .
�Sec.3097,Civ.C.).� .
� � � PLAN CHECKING FEE , � . . �
Lender's Name � �
�,Yyj�",5 � � PERMIT ISSUING FEE � f Q - '.
Lender's Address T` � , � � �
I ceriify tha�I hove re �his applimtion ond sta�e that the � TOTAL FEE . D���
obove information is correct.I ogree�o comply with oll County �
ordinonces and S�ate lawz regolating Eledritol wiring,and
hereby auihorize represen�atives of ihis County 10 eMer upon " � �
fhe obove-meniioned pro�f r inspection purposes. - - �
SEE REVERSE FOR EXPLANATORY LANGUAGE
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