HomeMy WebLinkAbout0976A (5) WORKERS'COMPENSATIONDECLARATION �' 78A663 APPLICATION FOR ELECTRICAL PERMIT �
• • ' •• - CE806G(2-80)
1 hereby affirm that I have�a certiticate of consent ro self ' - COUNTYOF LOSANGELES � . BUILDINGANDSAFETY .
insure,or a certifcate of Workers'Compensatlon Insurance,or - � � -
a,c�e{tiCed cop y thereoC(Scee.3800.Lab C.) � � '
(�/2Q J(�!-SJ y�Q/Lf�jQ�° �u]Z(�[,. FOR APPLICANT TO FILL IN JOB .
1'"olicy No. ComOa�f ADDRE55 � �
i � New Residential Bldgs.&Pools EACH NO. FEE
� Certitied copy is hereby furnished. 1&2-Pamily,Sq.Ft. $ — $ LOCALITY w/¢.��(/((r'
� Certified co � Mutti-family Sq.Ft. CROSS ST .
py is fiied with the county buildinQ inspeetion Residential Swimming Poots
depariment. �f - OWNER OR /�
Q yr p-/ . Q�/,� /}� � � �� . FIRM NAME T C ��
Dater� ��-� ApplicaML r�� ��� Outlets:Re Ligh Sw � �/� ) -
v d q�DRESS C..liSQ 1 '
. � s}g`�-f First 20 �
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.�rnG- Additional CITY �A/(� L�� o.��-f�37 }
' COMPENSATiON iNSURANCE a
� - . PLAN CNECK �
(This section need not be completed if the wotk involved . . d d U � 0 pPPLICANT � LJ
Lighting Fixtures First 20 ADDRESS
by the pe�mit is for one hundred dollus (5100)or less.) Additional 0 0
TO[al No.� � CITY Tsl No. I-
I certify that in the performance ot the work tor which fhis Fixed Appliances Not Over�1 HP �
permit is issued,I shall not employ any peraon in any manner pEHM1T W -
�so as to become subject to the Workers'Compensation Laws. Rarge_Heater D.W._ APPLiCANT N .
- � �� Oven _Dryer_W.M._ ADDRESS �� Z
Date Applicanl ToP —FAU YW.H._ -
Hoad_Fa� �LOther___. � ��Tv �e -Tel No.
i NOTICE TO APPLiCANT:[f,afier making this CertiRcate of Disp. _Room Air Cond._ � / � LI NS �2 G:,�n
F.xemption, you should become suM1ject to the�Workers' � REG.NUMBER,J �3 lea �V
� Compensation provisions of the Lebor Code,you muat forth- power Apperatu5&Large Appiiances . DISTFICT NO. PFOCESSED BV.
� with comply with such provisions or this permk shall be � �
� deemed revoked. Size&Type HP,KW,KVA,or KVA , .
. � � Up to 7 Incl. �
FINAL
I _ � Over 1 to 70�ncl. oATE VALIDATION '
I LICFNSF.D CONTRAC70R5 DECLARATION Over 10 to 50 Incl. - �
� FINAL
� I hereby afflrm ehat I am licenaed under provisions of Chapter Over 50 to 100 Inc. By • -
� 9 (commencing with Section 7000)of Division 3 of the Buai• Over 100 � '
nas and Rofessions Code,and my license is in full force and �
effect,. Services _
� . '330-384 �y�(� 0-200 Amp.Under 600�V . � v����� ,�� ! �
License Number Lic.Cleu
� n re t r���L�/�ate �1-1000 AmP.Under 600 V �` / �� .� .
8���� Over T000 Amp,or Over 600 V
. :j���uri� �7,E`r� '
HOME OWNER•HUILDER DECLARATION ' � �C
Temp.Power Pole&Appurtenanees . % .
i I hereby affitm that I am�eaempt from the Contractor's Sign with One Branch Circuit ' � '' , � ��
� License Ls�v for the folloa•ing reason (Section 7031.5.6usi- Additional Sign Bronch Cireuits . . � (j 2 9 Q
.�.� �
� ness and Protessions Code):
� Mise.Conduiu&Conductore ;� �,,,�j�q�`� �
� � 1, ai owner of the property,will do the work and the pthe�(See Complete Fee Schedulel— �
� structure is not intended or otfercd (or sak (Seetion � .
� 7044,Business and Professions Code). ,
CONSTRUCTION LENDING AQENCY !;�.Q[l�£��
� I hereby afflrm �ha[ there is a consiruction lending agency ' - �-- - � . � , .
� for the pertormance of the work for whith this permit is � pERMIT FEE (Sub-Total)
�- issued(Sec.J097,Civ.CJ. �" � � - �
� Lender's Name � '
. PLAN CHECKING FEE (One•Fourth Permit Fee)
�Lender'sAddress PERMITISSUINGFEE � - • � ,
1 certiCy that I have read this application and state that the TOTAL FEE �
above information is correcL I agree to comply with all Coimty
ordinances and State law-s regulatlng Glectrical wiring, and . , �
hereby authmir.e representatives ot this County to enter upon , _
tfie ove- entioned prope ty for'nspection purposes. � � . �
,,� SEE'REVERSE FOR GXPLANATORY LANGUAGE
Q'��/� �-�,�8'
Signeture of Permittee . Date , . � . ,
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