HomeMy WebLinkAbout1670A WORKERS'COb(PLNSATIONDECLAHATION �76A663 APPLICATION FOR ELECTRICAL PERMIT :
CE-BO6G(2�80) � �
I hereby affirm that [ heve a cert�ticate ot consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,of a certlfcate oF Workers'Compensation Insurance,or � . ) �
a certiFiedcopy[hereof(Sec.3800,Lab.CJ � � � � TC- �'' r�� ��—
��.j��t��� FOR APPLICANT TO FILL IN - JOB �
Poiic No � � Com an ���� -Ly�-� EACH NO. FEE • ��Z-� L
I Y �s-�-F P Y ADDRESS % `
New Resitlential Bldgs.&Poots
� Certified copy is hereby furnished. 7&2•Family,5q.Ft. S — 4 LOCALITY ��� � _ -
❑ MVltidamily Sq.Ft. — NEAR � - � � .� /
CertiFled rnpy is filed with!he county bu' i Inspectton Residential Swimming Pools CROSS ST p„�1.. J`S-Q ~•r J qiri
department. � - ` �.�RMENA E � G � ��../ 2 � .
Da[�-��/-�'`ilpplitan � Outlets:Re�Light_Sw..L—= �%� ��' MAIL ��.� �^L� ��
First 20 AD�RE55 � ^ . �
CERTIFICATGOf E PTION FROM WORKF:RS' Total No.� Additional � L CITY . ���[ � Tel No. M(,i/,
COMPLNS IOY INSURANCE , }
. . ' PLAN CHECK C+ ' � d
(This section need not be compieted if the work iOVOlvOS � '�� APPLICANT • � . p �
LightingFixtures First20 ADDRESS�L -) V
by the permit is for one hundred�dollars(5100)or less.) ,�[`j ��� �`L 7�),j' ! �
Total No.�_ Additional C O �
I certity that in.ihe erformance of Ihe wnrk for which this CITY � Tel No. O
ermit is issued,1 sha I not em lo an erson in an manner Fixed Appliances Not Over 1 HP - -�y` � .
P P Y Y P Y VERMIT .
so as to Aecome subject to the Workers'Compensation Laws. Range_Heater_D.W._ APPLICANT � ,P� � W�
� �� � Oven _Dryer_W.M., ADDRESS �, � ca �
- �t c:t. v �n
Top _FAU _W.H.._ Z �
Date ADP��canf � � - .
' Hood_Fan _Other_ CITY � Tel No.
NOTICE TO APPLiCANT:.[f,atter making this Certificate of - Disp. _Room Air Cond__ � LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER � Class�
Compensation prnvisions of the LaM1or CoJe,-you must fnrth• power Apparatus&Large Applienres - . DISTRICT NO. � PROCESSE BV
with comply w�ih such FfiO��510f19 nr this permit shall be Si¢e&Type HP,KW,KVA,o�KVAR�.
deemed revoked. � ��L�
� � Up to 1 InCI. FINAL n
LiCENSLD CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE .( I�� VALIDATION
Over 10 to 50 Incl.
�1 hereby af(irm that I am licensed under provisions nt Chapter � Over 50 to 100 Ina FIN �
BV I I
9 (cnmmencing with Section 7000)nP Divislon 3 ot the Rusi- p�e��pp .
ness and Fkofessions Code,snd my license is in full force and � . � .
effect. . f Services . -
License Num6er���� Lic.Class r'���� � 0-200 Amp.Under 600 V � , . �
� 201-1000 Amp.Under 600 V
Contractq� `� ' � Dare� � 4�'� Over 7000 Amp,or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances � .
Sign with One Branch Circuit ?1 b 7.0 A �
I hereby affirm ihat I am exempt frnm ihe Contrscror's qdditional Sign Branch Circuits �
License Law for the followinR�eason(Settion 7031.5,Rusi- . �.• , • �'� �
ness and protessions Code): - � � .
� Misc.Conduits&Cnnductors � � • •6 6 9 0
� [,as oHmer of the property,will do Ihe work and�he Other(See COmplete Fe9 Schedule�—
strucmre is not intended.or offined for snle (Section � � � • • •6 6 9 G�
' 7044,Business and Profesxions Code). , , . �
CONSTRUCTION LLNDING AGIiNCY � . � O Z P S'"8 2
1 hrreby aifirm that Ihere is�a cunstruction lending aRency •
for the performance ot ihe �vork for.vhich this permit is pERMIT FEE (Sub-Total� �
issued(Sec.3097,Civ.C.).. , � � �
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Feel
Lender's Address � pERMIT ISSUING FEE - ��j - �
(certify that I have read this application and state that ihe TOTAL FEE , ��Q(7 - -- - � . � f
above intormation is correct.1 agree to comply with atl County . �
ordinanres snd State�laws regulating C•lectrical wiring, and
herehy authodze rep 4�atives nf Is County to enter upon � ,
. the ah ve-mentione p p rty for' pection Purposes. � � SEG'REVERSf FOR EXPLANATORY LANGUACE �
, '� -�jZ_
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