HomeMy WebLinkAbout0901A WORKERS'COMPENSATION DECLARATION 76A663 ,o,a� - APPLICATION FOR-ELECTRICAL PERMIT �
. I hereby c��'rm Ihof I hove a cerlificole o(consenl lo self - CE-806C
in:'ore,or a certificote of Workeri Compensaiion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
o1ro'6'�5@r�i(�'S�cop�reof(Sec. ,Lob.C.) 3
❑oP'T'it�o �x4 Compan FOR A►►LIGM TO flll IN . JOB �
Certified copy is hereby furnished. New Residential Bldgs P��o� EACN NO. �E ADD ��
�/Cerfified copy is filed wilh 1he tounfy buildinq inspec- I 8 2-family,Sq.F���_ f — s ��A��N . . '
ti n depor�menl. - Multi•fomily Sq.Ft. — NEnReSt
. Rasidenfial Swimming Pools � OwNER T
Date�a�Applicom F t'�"4� . . . ,
FIRM
. CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec�light�+_Sw.� '�'�� -
COMPENSATION INSURANCE - ADORE55
�1 (ihi��rdion need not 6a complNrd if fhs work involred by Tatal No.� Addifonal " �I Tel.N -. �
ths p�rtni}1�tor on�hundrod dollan(5100)or l�ss.)
�I terfify�hat in 1he�performonce of the�work for whith�his . . q�ppN�,�,e,MK - _
permil is issued,I shail not employ any person in any mannar
4o as�o become subjeU to�he Workers'Compensolion Lows. Lighiing Fiztures Pirst 20 ADDRESS �
i � � � � . Addirional
\ - � Total No.� CITY ' Tal.No.
\_ 0pplitant � Fixed Applionces Nol Over 1 HP . PERMIT
]:.E TO APPIICANT: if, aftar moking this Certifico�e of APft�CANT �
�,Rpfion, yo� should become subject �o the Workers' Ronge_Heater_D.W._
xnpensation provisions of the Lobor Code,you most/orth- Oven _Dryer —W.M.�— ADDRESS -
r��h comply 'Ih such provisions or this pe�mit shall be Top _FAU —W.H.— C�T • Tal.No
Ieeined revoked. � �� � Hood _Fa� _Oiher_
LICENSED CON7RACTOR$OECLARATION- �KFNSE OR
lheieby offirm that I om lice�sed under provisions of Chopter 9 Disp. _Room Air Cond. — REG.NUMBER ��Ou
(commencing wi�h Section 7000)oF Division 3 0(the Business - DISTRIGi NO. �ROCESSED BY '
j Power Apparatus&Large Applionces . .. Y
ond Prafeuions Code,ond my license is in(ull iorce and effecf. p, .
- � Q�1 �(� �� Size 8 Type HP,KW,KVA,or KVAR� �D n O
License Number�1��/�`�Lit.Closs `3e=.LL -� � FINAL V
---...� -Up10 1 Incl. . .
Controctor `� Do�e� Over 1 to 101nd. DATEL � VALIDATION Q �
!– G�
�Over 10�o SD�ncl. V
❑; I om ezempt under Sec. - Over 50 to 100 Inc. - BY . .. . , �++
– '� B.BP.C.for this reoson Over 100 �� Z �
Dafe: - � Services,�5w6d.,MCC&Panelboords � � � � �
� . _ 0-200 Amp.Unde�600 V �
Si9narure 201-1000 Amp.Under 600 V� � � _ .
O ' Ovet 100D Amp,or Over 600 V � ;
Exempiion far Reg.Maint.Elecl. %
+ l. SINGIE FAMILY Temp.Power Pole 8 Appurtenances � . . .
�• HOME OWNER•BUILDER DECLARATION - � �� - �
Sign wilh One Bronch Circuit .
j �I he�eb�affirm�hat I am exempi from ihe Contractor's ticense Additional Sign Bronch C�rco��s� � � c�O 9 Q� A
Law for the following revson(Sec�ion 7031.5,Business and �
Profe:sions Code): � . �
� � Midc Conduifs 8 Conducfors � � -� _. #s • • • a'Z
I,os owne�of the property,will do fhe work and the
slrutWre is not intended or oNered for sole �Seclion Other(See Complete Fee Schedvle)_ ► . __. 1 +3 6�2 7_ �
701E,Business and Professions Code). � � '
CONSTRUCfION IENDING AGENCY � � �,J 6'''2 7�' '
I hereby offirm�hat rhere is o tonsiruttion lending ogency for �&�Q_$7 .
Ihe performonte of ihe work fo�which this permit is issued PERMIT FEE - ' � (Sub-Tolal) � � ... '
(Sea 3097,Civ.C.). � � � � � � �
�. � - PIAN CHECKING FEE - � � - � - . . .
lender's Nome �
VERMIT ISSUING FEE- - �
Lender's Address � � r� �
I Certify thol I have�eod this applicotion and slafe Ihat the TOTAI fEE � � / �
obove informotlon is torrect.1 ogree rv comply with oit Co�ny �
ordinontes ond S�o�e lows Fegulo�ing Electriml wiring,and . _
hereby ou�haize�epresema�ives of Ihis Couny to enter upon � - - � �
the above-memioned property(or ir+spection porposes. SEE REVERSE fOR EXPIANATORY LANGUAGE
L'Ylff_J h�0�_. ... . ....
� Signature of Permitiee ate � .
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