HomeMy WebLinkAbout0611A (4) •WORKERS'COMPENSATION DECLARATION � 7snees ,o�e, pppLICATION FOR ELECTRICAL PERMIT �
I hereby affirm that I have a certificate of consent to self Insure, Ce-sosc
or a certificate of Woikers'Compensatqn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copythereW 3800,Lab.C.)
Poiicy No.�y�omparty '��/IIV CTJL//�'C FOR APPUCANT TO FlLL IN JOB S`'7�� � � %t f�/t.
.❑ Certified copy is hereb turnished. //✓�. EACH NO. FEE AD�RE55
, Y . ./ . New Residential Bldgs.&Pooi��// n �� T�
1 8 2•FamilY.Sa.Ft. � S � — S LOCAl1TV K.. J,_
� Certified eopy is filed wilh the ounty building insDection — NEaaESi
� � �, Multi-family Sq.Ft.
�j'J Residential Swimming Pools cpwNEp op • �
Date Appli�an , FI(iM NAME '�!�
- CEFTTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ree—L'ght_Sw.— � � ' MA�� J � ��
� -� � COMPENSATIONINSURANCE ADDRESS
(Thls sedbn need not be eompleted II the work Involved by the First 20 CRY ` el.No.p
permlt is tor one hundred dollars($100)or less.) Total No. Additional P C[.. D
I certify that In the performance o1 the work lor which this permit �uN G+ECrc
Pf'PLICAM
is issued,I shalt not employ arry person in any manner so as to
become wbled to Ihe Workers'Compensalion Laws. L'ghling Fixtures First 20 � ADDRESS �
� . Additional �
� � Tolal No. CITY � Tel.No.
Date � Applicant Fxed Appliances Not Over 1 HP PERrAT
N"'�CE TO APPLICANT: If, aRer making this Certilicate of //������ � .
)ption,you should 6ecome subject to ihe Nbrkers'Compensatbn Ran9e_Heater_ D.W. _ APPLICAN7
. provisions of the Labor Code,you must forthwith comply with such Oven_Dryer_ W.M._ ADDRES ,(�. � ���
provisions or this permit shall be deemed revoked. Top —FAl) _ W.H._ - CITY �(,Q �70�Tel.No.
LICENSE�CONTRACTORS DECLARATION Hood_Fan _ Other_
I hereby.alfirm that I am liCensed undef provisions of ChaDter 9 Disp. _Room Aif Cond. _ uCENSEOR . ��!1 . . Class �
(commencing with Section 7000�of Division 3 of the Business antl aeG.NUMeea �/(/
Protessions Code,and my license is in tull force and effect. power Apparatus 8 Large Appliances OISTRIGT NO. PROCESSE�BY - ��
�7�.�7�3 LiC.Class C— U Size 8 Type HP,KW,KVA,or KVAR \ O �Q,O O
License Number V v Up to 1 Incl. FINAL 0
Contractor�7�Z?YC-f C19��—o�ie-_� oYer i fo io i�ci. °^rE /��/�� VAUDATION_ O�
Over 10 to 50 Incl. FlNAL / �j
❑ I am exempt under Sec. . Over 50 to 700 Inc. BY ^ ..-� . . . {y�
B.BP.C.for this reason Over 100 �`��"��� �
' Services,Swbd..MCC&Panelboards � � Z
-- Date: D-200 Amp.llnder 600 V
Signature 207-1000 Amp.Under 600 V �� �O�7�,� A
❑ - -� Over 1000 Amp.or Over 60D V {�� � e � �2
Exemption far Reg.M2int.Elect.
-- -'- � - SINGLE FA1dILY -� � - � Temp.Power Po!=8 Appurten=_nces � e .g 2,q[;
HOME OWNER•BL1IL�ER DECLARATION Sign with One Brarxh Circuit
�by altirm that I am exempt from the Contractor's License Law s e �,e 4,
e Ie!!a•dn3 ro=_=_on(S=ction 7D31.5,Busin=ss and Pro?e«ions Additional Sign Branch Ciraits °8- � �
�e): 0$05—F38
❑ I,as owner of the property,wil�do ihe work and the strutture Misa Conduits&CoMudors � . ,
Is not interided or offered for sale(Section 7044,Business 01her(See Complete Fee Schedulel_ ►
arid Professions Code).
CONSTRUCTION LENDING AGENCY � �
I hereby affirm that there is a constructbn tendirg agency for the �
performanee o1 ihe work for which ihis permit is issuetl(Sea 3097, .-. PERMIT FEE --- � �- � -� �-(Sub-Totaq� � � � � - � �� � � �
Civ.C.).
PLAN CHECKING FEE .
Lenders Name
PERMIT ISSUING FEE ,. . _�O , , . _
Lenders Address - �
I certify that I haYe read this application and state ihat the above TOTAL FEE �a q
information is carect I agme to comply with all County ordinances �
and State lavrs regulatirg Electrical wiring,and hereby authorize
representatives ol this County to enter upon the above• entioned � � - - - �
p for inspection purposes. SEE REVERSE FOfl EXPLANATORY LANGUAGE
I.C/LJ /1 �� �� Ut�... . .
Signature of Permittee Date '
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