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HomeMy WebLinkAbout1076A WORKERS'C061PENSATIONDECLARATION 76asa3 ,o,e, qppLICATION F�R ELECTRICAL PERMIT — � � I hereby afGrm tY�t I have a certificate of consen[to self insure, �'BDGG • � � a a ccrti�icate ot Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thcf1eof(Sec.3600 a6.C.) �,�/� <�� ��,p PoIiCy Nq��Cpmpany � —"'-• FOR APPLICANT TO FILL IN �-- "'- ' � qpDRE55 �v �i �/ �❑..R Certified copy is hereby furnished. . New Residential Bldgs.8 Pools EACH NO. FEE 1 T1. Certified copy is_filed�wilh the counry 6uiWing inspection ��z-Family,Sq.FC S — S LOCALITY ��� �t'� tlC �r�mAc� L Multl-0amily Sq.FI. — NEAFEST � �'JT� �p+ Residential Swimming Pools � Ca055 ST� � - Oate ppplicant � OWNEF70R FlFM NAME � , .CERTIFICATE OF EXEMPTION PROM WORKERS' , , � � � � � �- �� rn�vL - COMPENSATION INSURANCE ' ' ' ' OuUcts Rec L'gh�_Sw. � 1 O aooReSS �� ��L� � � (This seclion need not be compleled if the work involved by Ihe First 20 . permit is lor one hundred dollars($100)or less.) ' Total No.� Adtlitional GTY Tel.No. 6 $3 I cer6fy that in ihe performance of the v+ork for which IhiS permil P�AN CnECK �is issued,I shall not empio an - " � � APPUGNi y y person.in any manner so as to became subject ta lhe Workers'Compensation Laws.� ' - L'ghting Fixtures FirSt 20 . A�OflESS � �. � Total No.�_ �ditional : , Date � Applicant � G7Y� . Tel.No. � NOTICE TO APPLICANT: If. afler makirw this Certiifcate ot Fixed Appli�nces Not Over 1 HP PEar.uT Exemption,you shoud Cecome subject to ihe 1'lorkers'Compensalbn Range_Heater D.W. _ ^���^N� �~ �� � pmvisions oF lhe Wbor Coda;you must brthwith�cwnply with such Oven_Dryer_ W.M._ � MDRE55 �a �--- ---- �- - � provisions or lhis permit shall be daemed revoked. - � � ' Top _FAU _ YJ.H._ � CITY - Tel.No.���� � LICENSED CONTRSCTORS DECIl.RATIO�d Hootl_Fan — Other_ I hcreby affirm that I am licensed under provisions of Chapler 9 Oisp.._Room Air Cond. _ uGENSE OR ��� Class. (commencing with Seclion 7000)ot Division 3 of the Business and � , REG.NuneBER Pwfessions Code,and my license is in full force and eflecL Power ApparaWs&Largo Appliances DiSTRiCi NO. PROCESSE Y _ ,.. __._ . , �i Size&Type HP,KW.KVA,or KVAR l� Q Licensa Numbar � '�7? Lic.Class�_ ... ...... ...UP to 1 Incl. . _._ . . . . FINAL . __ . .. . .. . . V � Over 1 ta 1 D Incl. DATE � '(� C VALIDATION O -Cantracto Date�� - Over 70 to 50 Incl. - -� � � �~ � U ❑ I am exempt untler Sec. ' Over 50 to 100 Inc. gyA� � W B&P.C.far this reason Over 100 ��a� � ` N � Services,Swbd.,MCC 8 Panelboartls � � � � ► � - •�� . . Z .......... Data: . . 0-200 Amp.Under 600 V � � � � �i �� Signature 201-1000 Amp.Under 600 V � - � -� � �� 1 . .. . . - ❑ -- � � -- � - � � Over 1000 Amp.or Over 600 V Ezemption for Reg.MainL Elect. ... ..... .... . .. . .. ��� - � �� SINGLE FAMILY --- -- Temp.Power Pole 8 Appurtenances � HOME OYYNER•BUIIDER DECLARATION � � Sign with Onc Branch�Cimuit -� � �� � - � � - � I herehy aflirm tha[I am exempt from the Contractor's License Law qdditional.Sign Branch Circuits for the following reason(Section 7031.5,8usiness and Professions � - -�- ' , ,� Q,�,6� Code): z � � - Misa Condufts 8 Conductors� � � � I,as owner of Ihe propeny,will do the work and ihe structure ��• • • • •2 is not intended or oflered for sale(Section 7044,Business Other(See Complele Fee Schedule)_ . . and Proressans Code>. 1 • •G 1,�0 CONSTRUCTION LENDING AGENCY -�� �-�- � - -. - . . . - .- . . . • � �2�.O n� I hereby affirm that there is a wnstru[tion lending agency for iha pertormance of ihe xrork tor which this permit is issuetl(Sec.3097, pERM1T FEE - - - (Sub-Tplaq . .. . . .... O�'Z[j—8$ Civ.C.1. . _. _PLAN CHECKING FEE..._ _. _.... _.. .._.. ._. . � Lentlar's Name � I O PERMIT ISSUING FEE . _ ..... . . ._........ .. . .. . . . ._. . Lender's Address ��OO I certily lhal I have read lhis applicalion and state thal the above TOTAL FEE information is correct.I agree to comply with all County ordinances �� � � - -- - ��" � and St.^ aws regu�ating Electrical wiring,and hereby auttwrize � � repre N es of this County lo enler upon the above-mentioned ��"- -� �� ' "' � � � � - � �� - - � prop t or ispection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , n� _ .. . .. ._.. . . _ _ . _. _. . .. . '/' Signalu of Perminee Date � ma . m � � � m � �, m �n ma -o = - .. . . _m.c ��.:� .« r' L. .� C'� - •— - • '- . � - - ... ,_ . i . •�`-Ni� a o � �-�� 3:>.-a�, �` �;���tp � L � _� ' - �_ � .. '- - ,,. ' J �A '�,1 . � C � .d Q ti .�� � �N �. ,. � . ' .. . . . �� .N C .� � E.;4 c. .N�N �S Y 1 Q �' a �6 � � . 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