HomeMy WebLinkAbout0625A •WORKERS'COMPENSATIONDECLARATION 76A663 ,o,e, qppLICATION FOR ELECTRICAL PERMIT {�
I hereby affirm that I have a certifcate of Consent b selt insure, cE-eosc
or a Certificate of Workers'Compensation Insurance,or a certified COUNTY OF LQS ANGELES BUILDING AND SAFETY LJ
Cop�thereof(Sea 3r800,La6.C.) ,,• �.J
pplity N0. �/ mpafry.LLV���S��J�— FOR pPPLICANT TO FILL IN . J06 �
. ❑ Certitied to is hereb furnished. . fNP EACH NO. � FEE ADDnESS Q �� �
PY� Y ,. • New Residential Bldgs.&Poo
� Cetlified copy is filed with the��oimty 6uildirg inspedion 1&2-Family,Sq.FL� 5 — 5 LOCALIT �'�s�`l i�� �� "
� ffine � MUki•family Sq.Ft. — NEAREST Q p„�
? CROSS SL lYJ%L
Date �Jd� � AppiiCent r L Residential Swimming Pools pWr�ER OR� ,/
- � � �� � � FIRM NAME JC /7��C�
� CERfIFICATE OF EXEMPTION FROM WORKERS' - p�l�}y.Rec—L'ght_$w,— � MA2 y U
� COMPENSATION INSURANCE .. - -- nooneS f �/'
(This sectbn need not be completed if the work Involved by the First 20 .
permK le for one hundred dollan(5100)or kss.) Total No. Additional CITY �Os'�� �/ et.No� � �
.I certity that in the pertormance of the work for which this permit ., . . . PI.AN cneCK
IS ISwed,I Shall rwt empby any person in 3rry mannef 50 as t0 APPLICAN7
become wbject to the Workers'Compensation laws. � L'yhting Fixtures First 20� ADDRESS �
� Total No. Additional CRY Tel.No.
Date � Applicant �� � Flxed Appliances Not Over 1 HP
'� �CE�TO APPLICANT: If,-�after making this Certiticate ot PERMiT � , J �.�y��
ption,you should become subject to the Workers'Compensation Range_Heater_D W. _
APPL�CANT � `�RJ/VG
pmvisions of the Labar Code,you must forthwi�h comply with such Oven_Dryer_W.M._ A�DRESS ,Q, � ����
provisions o�this permit shail be deemed rewked. � Top _ FAU _ W.H._ � ��' � Tel.N
� LICENSED CONTRACTORS DECLARATION Hood_Fan _Other_ �RY i 9 � � �:5g/� � �
I hereby aftirm that I am licensed under provisions of Chapter�J Disp. —Foom Air Cond. — uceNse o� cias�� ,
(commencing with Section 7000)oF Division 3 0l the Business and �EG.NUM6ER
Profe55ion5 Code,and my license is in full(orce and eflect. DISTRICT NO. PRpCESSEO BV
Power AOParatus&Lar9e ADP�iances j'� . ,(y� a
(/f/��fA�1(�} Sizo&Type HP,KW,KVA,or KVAF� I(,J 1 �\q1 O(�-� 0
License Number ` �Vv15J Lia Class c�� Up to 1 Incl. FINAL -p' V
�-7 Over 1 to 10 Incl. DATE �.�D YY . VAL�DATION �
G/_R�L/C� Date . . 1j p°
Contracto� Over 10 to 50 Incl. �
❑ FINAL
I am exempt untler Sec. Over 50 to 100 Inc. BY /' ar+� W
B.BP.C,for this reason Over 100 " �.0 6 2 5 A �
. . _ . Services,Swbd.,MCC 8 Panelboards � �- - � , Z
Datc: 0-200 Amp.Under 600 V €(s s e o 0 2
Signature 201-1000 Amp.Under 60D V
�� � � Over 1000 Amp.or Over 600 V � e � Q j fj p
� ❑ Exemption for Reg.Maint Elect � � � � -
SINGLE FAMILY Temp.F'ower Pole 8 Appurtenances • • 1 G a S h c=i
\ HOME OVJNER•BUILDER OECLARATION Sign with On0 BrBnCh Circuit
Feby alfirm tha[I am ezempt 1rom tha Contractor's License Law �a�Jr—p$
..�the fo!lar�ing reason�Sedion 7031.5,Business 2ntl Pro!escions Addilional Sign Branch Cirwits - � -� -
Code�:
❑ I,as owner ol the property,will do the work and the structure Misa Conduits&Conductors �� � � -
is rrot interded or oflered lor sale(Section 7044,Business Other(See Complete Fee Schedule)_
and Pro�essions Codel. ,
CONSTRUCTION LENDING AGENCY � �
I heieby alfirm that there is a construction lendirx3 agency for ihe
performanCe ol ihe work for which ihis permit is issued�Sec.3097, pERMIT FEE (Sub-Total) 3 -
Civ.G).
PLAN CHECKING FEE - - - � � ��
Lender's Name
PERMIT ISSUING FEE (J - -
nder's Address
;tify that I have read this application and state that the above - TOTAL FEE . �Q3• . . . . .. .
mation is correct.I agree to comply wilh all Cwnty ordinances
5tate laws regulating Electrical wiring,and hereby authorize . _ .. .
�tatives of this County to enter upon the ebove-menlioned
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�.Le2 �� �
Permittee Date
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