HomeMy WebLinkAbout0814A (4) WORKERS'COMPENSATION DECIARATION 76A669 l0iel ,
I hereby atiirm thht 1 have a certificate of consent lo self �E.� APPLICATION FOR ELECTRICAL PERMIT
insure,o�a cerificote of Workers'Compensarfon Ins�ro�ce, COUNTY OF LOS ANGELES BUILDING ANO SAFE7Y
or a tertified copy thereay((Sec.3800,Lob.C.) �j
P❑ot�cy No.CZJ9!9 cp���y �/�jr7 . FOR APMICANT TO Flll IM �Ob
Cer�Ified copy is hereby furnished. New Residenlial B�d9s.&Pools � EnCH NO. FEE ADORE55 7Sd ,�/iQ./'10�/ /QB �
� 1 8 2-Famil q. LOCALITY�.
Cerlified copy is filed with the county building inspet- Y�5 F�� 5 — 5 A�NO
NEAREST
tion department. � Multi-family Sq.FI. ca055 57. �
Residen�iol Swimming Pools OwNER Ort
Dale�=�L�Applimnt -40'�- ,g�,/4�'
FIRMNAME
CERTIFICATE Of EXEM N FR WORKE �: ' � ' � Mna
Outle�s:Rec_Lighf Sw._ AODRE55
- COMPENSATION INSURANGE 5 b 7 pia�? d+v� dey
This��Nion naad nol be eom IN�d il fhs work fnralvod 6 First 20
( P y Toral Na. Additionol CITY Tel.No.
ths permif ls for en�hundr�d dollars(5700)or Isss.) �
I cerlify that in fhe performonce of Ihe work for whi�h fhis . qppij�ryTK _ ,
permit is issued,I shall nol employ any person In any monner
so os ro become s�bjec��o the Workers'Compensation Laws. Li9hting fiztures First 20 ADDRESS
Additional
� - Tolal No._�_ CITY - Tel.No.
Dale �ppliconi � Fixed Applionces Nof Over 1 HP PERMI7
NOTICE TO APPUCANT: If, after making Ihis CertiFicate of APPLICANT •�
Ezemption, you should became subject to the Workers' Ronge_Heoter_D.W.— .
. Compensofion provisions of ihe Lobor Code,you must forlh- Oven _Dryer —W.M.— ADDRESS f -O��R� �-`
v�i!h cemply wilh su:h provisions cr this permif shall be Top _FAU —W.H._ •
deemed revoked.- - - .Hood _Fon _O�her_ CITY- � el.No. 7„Q
LICENSED CONTRACTORS DKLARATION � Disp. _Room Air Cond. — LiCENSE OR Closs �
I hereby offirm fhat I am licensed under provisions of Chapter 9 REG.NUMBER 3Z0la�6
(commencing with Section 7000)of Division 3 of Ihe 8usiness power Apporotus 8 Large Applionces DISTRICT NO. PROCESSED BY } '
ond Prafessians Code,ond my lirense is in full force and eHed. , . . . d
- - � Size&Type HP,KW,KVA,or KVAR �-`�, Q
Litense Number 3�Gl�6 g Lit,Closs C'!� �_ �� � FINAL � � V
Up to I In�l.
� R �� �,�a/��.���� Over 1 to IO lnd. DATE ��IL.'�V a VALIOATION �
CoNractor �� Over 10 to 50 Ind. � �F
❑ FINAI ,
I om ecempt onder Sec. Over 50�0 100 Inc.._ BY � W
B.BP.C.for�his reason Over I00 n'
N
�Date:- �� - � Services,Swbd.,MCC 8 Panelboards� ► � � � z
0-200 Amp.Under 600 V _
Signalure 201-1000 Amp.Under 600 V � � �
OOver 1000 Amp.or O�er 600 V
Exemption for Reg.Maint.Elect.
SINGIE FAMILY . Temp.Powe.r Pole 8 Appurtenances �
HOME OWNER-9UIlDER DECIARATION Sign wi�h One Branch Circuil
I hereby affirm tha�I am exempt from ihe Conlrodor's License qddit�onol S�gn Branch Circuik �O$-�.4 A
Law for ihe following reoson(Section 7031.5.B�siness and - �
Professions Code): � �
�•.�'.� �,'2
� �Misc.�Gonduirs&Conductors - � � -
I,as owner of the property,will do�he wark and Ihe ��• •2�j,5 0
structure is no�in�ended or ofFered for sale(Sedion Other(See 6omple�e Fee Schedule)_ • � . ,
7044,Business and Protessions Code�. � , � • •�•C�J.rJ 0 c=.o
CONSTRUCT�ON IENDING AGENCY � � � ' O G� E3�H S
I hereby afiirm lhot Ihere is a tonstruction lending agency for
ihe pe�formonce of Ihe work lor which this permit is issued PERMIT FEE- �- -� �(Sub-Totol)� � � - _ . . _ .
(Sec.3097,Ci'v.C.).
PLAN CHECKING FEE� - . . . .., � _ __..
lender's Name �
PERMIT ISSUWG FEE �O . . _
Lender's Address � �
I certiiy that I have read this applica�ion and state thot the TOTAL FEE
abave information is correcl.I agree�o comply with all County �
ordinances and$�ale lows regulaling Eledrical wiring,ond� , . .
here6y au�harize represen�a�ives of�his Counry to eNer upon ' � - - �
the above-mentioned property for inspec5on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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