HomeMy WebLinkAbout1645A 1845B - � WORKERS'COhiPGNSATION DECLARATION 76A663 ! � �
CE-806G 12-B01 APPLICATfON FOR ELECT�ICAL PERM{T �
I hereby atfirm ihat I have a certiticate o�consent to se�t COUNTV OF LOS ANGELES BUILDING AND SAFETY
- insure,or a certificate of Workers'Compensstion Insurance,nr . � lO
a certifiedtopy thereof(Sec.3800�Lab.C.)
��.' � � -1Y11C_ �YIL FOR APPLICANTTO FILL IN Jpg L�
Noiicy No Company ADORESS 1 �,11_
New Residen[ial Bldgs.&�ools . �EACH NO. FEE � ' �
� Cerlifled copy is hereby furnished.� 1&2-Famlly,Sq.FL s — $ LOCALITV
- � Multi•family$q.Ft. '-' N AH ST � _I, � • �t'� �
❑ Certified rnpy is filed with ihe caunty bu'��' g'nsDection . CROSS ST ryy,,,C}t�e:
Residential Swimmingppoonn11`` ' .
�e artment. �/p OWNEROR /�� �� �/' �,� /
,ry P�9`�� �-��'(-'- �J . FIRM NAME G Gw'�a^�'�-/�t,� C�
Data,��`'XpplicaR / �� Outlets:Re�ight�~Sw.�� b(� ��i MAIL � �
� First 20 ADDRESS rU - � + . h���i.��
CERTIFICATE OF EXEb1PTION PROM WORKERS' ' Total No.� Additional CI7v � Tei w� "
� CO'�fl'GNSATION INSURANCG . ^ 1 � "- • � �' -
• .+�0 iLAN CHECK /�/ a �
� APPLICANT 'J Y�/�G �-/(� O
(This section need not lx completed if the work involved ' �j f+ Z U
Lighting Fixtures First 20 ooRESS � - )it�, -�-L Z�r "
6y fhe permit is for one hundred dollus (5100)or leu.) v - C C'LL . ,y�
Totai No.� Additional U �
certity ihat in the performance of ihe work for which this CITV ��!_� �;,`Tel No. '�fy/,�'-_+^Jli� �'�
Fixed Appliantes Not Over 1 HP �
ermit is issued,t shali not employ any persnn in any menner PERMIT / V
�as to become suhject to the Wnrkers'Compmsation La�vs. Range_Heater_D.W.__ , APPLICANT :>'� a �
� - � Oven _Dryer_W.M._ ADORE5S % ��v C��� � LU Z
Ce � AOplicsnl ' ToP —FAU _W.H._ � —
CITV Tel No.�'.
Hood_Fan _Other_...— � Cl'`- � �
hICE TO AYYLICANT:If,after making this Certificste ot Disp. _Room Air Cond._ LICENSE OR
� ption, you shnuld betome suhject to the-Workert' � � REG.NUM6ER�' Class -'��i
�pensation provisions'of the Labor Code,ynu must forth• power Apparatus&Large Appliences oISTRICT NO. PROCESS D BY �
� comply with such provisions or this permit sh3i1 be Size&Type HP,KW,KVA,or KVA � '
,��emed revakeJ. - � � \� ���
i � . � � Up to t Incl.
FINAL
LICENSGD CONTRACTORS DECLARATION Over 1 to 10 Incl. � DA7E� ���, VAIIDATION •
Over 10 ta 50 Incl.
I hereby atfirm that I am licensed under provisions of Chapter Over 50 to 100 Inc, FINAL �
BY
9(mmmencing wi[h$ection 7000)o(Uivision 9 nf ihe Busi- Over 100 �
; ness and F'rofessions.Code,and my license is tn full force and � ���- �
etfect. , gervices � � G S,�b Q.5 A
�'� � 0-200 Amp,Under 6D0 V L
LiCense Number -� � Lia Class �-�� � � ' �
! .�;, 201-1000 Amp.Under 600 V #• •• . •2, �
Contractor�����.�'- �y Date - �7 •�C_ Over 1000 Amp.or Over 600 V � , .
' I • 1 3 5..9 0
HOM1fE OWNER-BUILDER DLCLARATION Temp.Power Pole&Appurtenances -
c=i
I herehy effirm that I am exempt from the Coniractor's Sign with One Branch Circvit � . • • 1 3 5�9 0 �
License Law for the foltowing reason (Section 703I.5,8usi• Additiona�Sign Branch Circuits �Z 2�3�$2�
ness and 1'rnfessions Code): �
• Mfsc Conduitz&Conductors � .
� I, as owner ot[he property,wili dn ihe work and the Other 1See Complete Fee Schedulel— � � � �
stru[ture is not intended or oftered fur sale (Sectiun �
7044,Business and Professions Code).
CONSTRUC710N LENDING AOENCY .
I hereby aftirm that there is a construction lending agency � � . �
Por Ihe performance�ot Ihe work for which this prrmit is pERMITFEE (Sub-Total� •7 �. '
issued(Sec.3097,Civ.CJ. � : - � -
LenJePs Name PLAN CHECKING FEE ' (One•Fourth Permit Fee1 �f'" �
LendePs Addrets pERMIT ISSUING FEE � o� •� — __
N � ,� `
I ttHity that 1 have reed this application and state that Ihe TOTAL FEE � � - v •
above information is corre . ree to cnmply with ail Connty Cd R A �.p� �
ordinances and State w re lating Electrical wiring, and � 35 �� � �• cn tn n
hereby authorize repr e iv of Ihis Covnty to enter upon � , � p� n� R7 _, ,��
theabove-mentioned ro rty or inspe ion purposes. SLE'REVHRSE POR ERPLANATORY LANGUAGC N��� � '� � -
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ignatureof ermiltee • �ate
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