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HomeMy WebLinkAbout1723A WORKERS'COMPENSATIONDECLARATION 76A663 ,o,B, APPLICATIOf� FOR ELECTRICAL PERMIT {� � I hereby yffirm that I have a certificata of consent to self insure, cE-eo6G . or a certi�ieate o1 Nlorkers'Compensation Insurance,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY �� copy thereot(Sec.3800,Lab.C.) ' ' � Policy No.� � � ('pRiParry/�S/�i9�-I/t/�. FOR APPLICANT TO FILL IN . . . . .JOB /J,/ E�� ^J. . � Certified copy is heraby.furnished. . ,•; � New Residential Bldgs.8 PoWs p EACH� NO. FEE ADORE55 O�7 .(..�'� � ' . . .. 1 8 2-Fami� Ft. ol � = S LOCALITY ,� �' 7 . . CertiFiad co(ry is filed with the county buikiirg inSpection Y��• ~ � rime Multl•fdmily$q.Ft. NEAREST, � � �� " 1�n� � Residential Swimmirg Poois � � pw Eli oR ����1� Date AppliCant ; _ � � FIRM NAME v T' i.. .-.. ... � -� CERTIFICATE OF EXEMPTION FROM VYOf7KERS' �• ` � Mat� •� � �� �.COMPENSAT�ON WSURANCE . - � � Out�ets:Rec—L'ght_Sw.— � qppqE55 � �I�� /TV1/� �� �� (Thb seetbn need nol 6e complaMd N lhe work Involved by the First 20.��' " � � �permit is tor one hundred dollara(5100)a less.) - Total No. Addilional � - ��T ��,�q 9xa I.No�C(7�f I certiy that in the pedormance oi the work ror which th�a permit , APPPLICANT K is issued,I shali�Irot empby arry parson in arry manner so as to ' . -�-���-� � -.� � �- become subject to the Workers'Compensatbn Laws.. ., � Llghtirx3 Fixtures First 20� ADDRESS-�� - �-� -- � � � - � -� � ' � Total No. Add'rfional. . CITY- � � Tel.No. �ate AOPlicant � -� ' - "'�� Fxed Appliances Not Over 1 HP NOTICE'TU'APPLICANT: It,.�aiter'making this (�RrtifiCate ol , PERMIi /��ry C/ ` Exemption,you shoukl become subject to the Workers'Compensation Range_.Heater_�.W. _ APt�LiCaM u cC , provisions of the Labor�Code,you must forthwith comply with such Oven_Oryer_ W.M._ ADDRESS � x /f f� � proviswna or this Permit shall be deemed rewked.. . . . . . ..- -..ToP...—.FAU _ W.H.._-- �---�- -- .. . - CITY /, - p, p .. . --Np�i��,l�� LICENSED CONTRACTORS DECLARATION , Hood—Fan _ Other_ /Jl/�/� /�7�p Tel. I hereby aHirm that I am licensed under provisions of Chapter 9 � Olsp.'�—'Room Alr Cond. ..-_.-- ��CENSE Or�__ �7 (commencing with SeMion 7000)of Division 3 of the Business and — REG.NUMBER V v � �- - -���g -�� Pfo(esslon5 Code,and my licen5e i5 In�ull fOrce and eHect. pp�yer ApparatUs d Large ApplianCes---� � . OIS7AICT NO. PROGESSED BY n-2 � Size&TyDe HP,KW,KVA,or KVAR ,�V `'`0.�G.3 n � p - L�ense Number d�J Lic.Ciass ��U ... _. _ .._ _. _ . . . . . V . .. .. Up to 7 incl. ..._... . .. FINAL.���� ' � �.r� Over 1 to t0lncl. DATE � Contracror �e��G�� Date � � VALJDATION . Q Over 10 to 50 Incl. FINAL ~ ❑ W I am exempt untler Sec. � �' �� � ��� �--� Over 50 to 100 Ina . gy... . .. . . . .... B.&P.C.1or this reason Over 100 N . .. .. .. _.. _ .. _ .. . . _. � � Services,Swbd.,MCC&Paneltioards �� -- - � - -�-- � � -� �- "- '��- ��- � � ���-7 2��n� Z -���� Date: 0-200 Amp.Under 600 V Signature �- 201-1000 Amp.Under 600 V-�--� � - - �- - - � -�-"'" , �" " '"' � ' �"� � ��� ° �2 Q . _ _ o��i000 nma.o.o�e�soo v I . .8 2 9.4 Exemption for Reg.Maint Eiect. � _- .. . . ._ . � �:•;. ���SINGLE FAMILV � � ����� . Temp.Povrer Po�e&Appurtenances __. e e_�_,G i��_ _ .' -- -. ... .... ... ..._ . _._ HOME OYJNER-BUILDER DECLARATION Sign with One Branch Circuit I heleby affirm thnt I am exempt trom the Contractor's License Lzw � ..__....O 0 2 O-�C� for Ihe follpwi�g reason(Seclion 7031.5,Business and Prolessions -�- Add�tbnal c�n Rrerv,h C��c��?s - - - - � ��--�� � -�- -• -•• --- Code1: � �� Misc.Conduits 8 Conductors-- -'�� - - � � � " ' �" "� "��� �' ��-" � -" �"'"" I,as owner o1 the property,will do the work and the stlucture Other See Com lete Fee Schedule is nOt intended or otfered fa saie(Section 70aa,Business . ( p .�— ' . .. . 'and Pmfessions Code�. ►.._ . . . ._ . ... _ .. _ .. CONSTRUCTIDN LENDING AGENCY -� - � -' -- - ---� --- �- -'-' - - � �� � �--�'�- � �-�� I herehy affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,--- pERMfT FEE� � � ������ � �" �" � (Su6-Totat)� �' � ��� '�� -� - � - �- - -' � Civ.GI. . . . ....---�-� PLAN CHECKING FEE � �� - �� - - - - _ � � ��� �� ��-�- �� � - -- � Lender's Name �� PERMIT ISSUING FEE � - - - - � - � � �� . .. .. ... ... ..... ....... ... . .._... _ Lender's Address � �� 1 eertiry that I have read this applieation and state that the above TOTAL FEE... .. . ... . .... . . . . . , , information is Corred.I agree to comply wilh ail County ordinances and State laws regulatlng Electrical wiring,and hereby au[horize. . . . . .. . . . .. . _._ . . _ _ _ . ._ .. representatives of this County to enter upon the above-mentioned tor Inspection purposes. �� ��//_�I_ - -- SEE REVERSE FOR EXPLANATORY LANGUAGE�- - ��� � -� ��- � ���� �� - �-� ----�� -� -- !� �p Signature of Permitteo Date . ` „. , _ ,�,;, � �-_--, .. . _ . ,� :1.- --i` ,f ; —I--;--i--.I`/..I I__.I f�..I_._' , !,- ,. ; i ; ; � _ 1 �� : .:i Y' I /' 'i i ' .- �� 'i!• � /, i ; i ;� � i' i � I�. ;;: 1 �y !i. � " , I i�; ! � � ` 1 -.� �; �� �i, i � � �i�i� j i' ii� �^. i . - ti �� . � � .- I : � . it^ i I ' !. 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