HomeMy WebLinkAbout0961A (5) WORKL•'RS'COMPENSATIONDECLARATION ��' �BA863 � APPUCATION FOR ELECTRICAL PERMIT� �
� CE�BO6G(2�80)
1 hereby atiirm �hat [ have a certificate ot consent to self. COUNTY OF LOS ANGELES - BUILDING AND SAFETY �
insure,or a certificate of Workers'Com ensation Insurance,or � y. y
ac rtifiedbtopy hereof($ect3800 LpbPC.) � ��f�r ��+
WG�Lt!Q•�'�O"Z-'c�b'—y�f FOR APPLICANTTO FILL IN ' Jpg n
Poiicy No. Company ADDRESS ` j ) � [y Z, .
New Residential Bldgs.&Pools EACH NO. FEE •
. Certified copy is hereby turnlshed. 1&2•Family,Sq.Ft. S — S LOCAIITY �ryN � .
Multi•family Sq.Ft. N
ertified copy Is fited with Ihe county building Inspeclion � CFiOSS ST
Residential Swimming Pools
dep ttm nt. . . . OWNER OR �
�jy FIRM NAME � Q
Dat� 'Applicant putlets:Rec�Light_Sw.�2.L— 6A �j � AO�RESS vC� '�/b
First 20
CGRTIFICATE OF EXEM TION FROM WORKERS' Total No.j2o Additional � �b � � " CITY � i Tel No. � �
COMPENSATION INSURANC6 PLAN CHECK r a
APPUCANT �O t C. �
(This section need not be completed if the work invo►ved Lighting Fixtures First 20 r U
6y Ihe permit is for one hundred dollazs (5100)ot 1e35.) , AD�RESS
Additional � �
Total No.� 3 O
1 certify Ihat in the perfnrmance of the work for which this � CITV /V C� " Tel No. �
Fixed Applianees Not Over 1 HP L�
� Dermit is issued,I shall not employ any person in any manner iERMIT Py- W
so as tq become subject to the Workers'C�mpensalion Laws. � Ran9e_Heater_D.W. APPL�CANT /Z� C�%( p.
- � Oven _�ryer_W,M,_� ADDFESS � � ��(f� U•. Z
Dat�z�J�/j'i APP�icant Top _FAU W.H.._ .. . �, —
� Hood_Fan �Other— �r Ci7 ��7e1 No.J� Z
NOTIC�TO APPLICANT:If;after making ihis Certificale oi � Disp. _Aoom Air Cond`_ — � J LICENS OR �f .
�Exemption, you should become subject to the�Workets' ; REG.NUMBE Clns �"�F7
Compensatlon provisions of the La6or Code,you must forth- ' poyyer Apparatus&Large Appliances � DISTRICT NO. PROCESSED BV
with comply wdth such pmvisions or�this permit�shall be��j - . � `\ . .
deemed revoked. Size&Type HP,KW,KVA,or KVAR �O ��
- � Uptol If1Cl. FINAL .
LICENSED CONTRACSORS DECLARATION Over 1 to 10 Incl. DATE ,[� i��� VALIDATION -
Over 10 to 50 Incl.
1 hereby affirm that 1 am Ilcensed under provisions of Chapter Over 50 to 100 Ine. FIn714L �
9(commencing with Section'1000)of Division 3 ot[he 9usi• Over 700 BY
ness and Professions Code,and my Iicense is in fuli force and � �
etfect. � �i Services �
License Number_i�ic.Class-� �""�{L_ � .0-200 AmP.Under 600 V . . .
201-1000 Amp.Under 600 V
Contractor Date 2 Over 7000 Amp,or Over 600 V
HOME OWN -BUILDER DECLARATION ��' Temp.Power Pole&Appurtenances . . . � �
! hereby atfirm that 1 am exempt from the Contrscror's � Sign with One Branch Circuit �
License Law for the following reoson (Sec[ion 7031.5.Husi- A�f�iitinnal Sian Branch Circuits
ness and FRokssions Code): ' ' . . .
� Misc.Conduits&Conductors � � . ,y
� 1,as owner of the property,wiil do the work and the Other(See Complete Fee Sehedulel— � 2 O 9(j',� A I
sttucture ie not intended or oftered for sale (Section . � . .
7044,8usiness and Rofessions Code). ' #�_�� �'�,�
� CONSTRUCTION LENDING ACENCY . �
I hereby affirm that there is a construction lending ngency � . - � �
fm the performance uf the work tor which Ihis permit.is pERMIT FEE ' (Sub•Total) 'r'�, ���3 0
issued(Sec.3097,Civ.C.). � � �
Lender's Name pLAN CNECICING FEE (One•Fourth Permit Fee) ������4'`�Q�
LendePsAddress - � � pERMITI55UiNGFEE �, _ � ��20:9.�-5� �
I ttrtity ihat I have read this apD���ation and state that the . TOTAL FEE v Q .
above Information is coirect.f agree to comply with atl Connty .
ordinances and State.�aws t gulating EleMrical wiring, and �
hereby authorize tepresentatives ot this County to enter upon � � .
the a ove-mentioned property for inspection purposes. SLL-REV ERSG FOR EXPLANATORY LANCUAGE ' �
�i na e of Permittee . �/ Date . � .
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