HomeMy WebLinkAbout0954A WORKERS'COMPENSATION DECLARATION Z°�°°roo°�`�3ie� APPLICATION FOR ELECTRICAL PERMIT Q
I hereby a(firm thot I hove a ceni{��o�e of consenl to seH �A�
insure,or a certifica�e of Workers'Compensation Insvrance, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
or a cert7fied copy thereof�Sec.3900,Lab.C.)
0 �.�.
Po��ty N���Ompony �(iu FOR APPLICANT TO Plll IN !OB �
�Cerliiied copy is hereby fumished. � New Residenrial Bldgs.8 Pools EACH NO. pee .4DORE55
Certified co is filed wi�h the couN buildin ins ec- I 1 8 2-Famil 5 FL $ — $ LOCALITY
PY Y 9 P ' Y Q NEAREST � \�
�tian deparlm{e�npL � Multi-family Sq.FL �ROSS ST.
Do�e��LLApplicam�����- Residential Swimming Pools pwNER OR � �
iIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' �� putlett:Rec_ligM z Sw._ ��� � �
COMPENSAT�ON INSURANCE '�., � 'fs A�DaE55
First 20 i
(Thts�ectlon n�ed not b�compialed if tha wor�tevolved b� ��. Totol No. � Additional UTY Tel.N
}b�p�rmH is for on�huedr�d dollor�(5100)or I�tt,) . PIAN CHECK
I certify fhot in 1he performonce of Ihe work ior whith ihi5 , APPIICANT � �
permil is issued,I sholl not employ ony person in ony manner � '
so os to become subjec�to the Workers'Compensa�ion Lows. � L'9hting FiKmres Fi�s�20 ADDRE55
� . - Additionol
� 7otal No, CITY Tel.No.
pore Applimnt Fixed Appliances Not Over 1 HP pERMIT
NOTICE TO APPLICANT: I�, ofter moking this Certi(imte of qpPUCATION �� J
Ezemption, you should become subjed lo'1he Workers' Range_ Heater—D.W. _
Compensalion provisions of Ihe labor Code,you must forth• � Oven —Dryer —W.M.._ ADDRESS � V L[�
with comply with such provisions or this permit sholl be , 7op —FAU —W.H.—
deemed revoked. Hood —Fan —Other— CITY�. � �Q fjel.No. �^�r 1 .
� LICENSED CONTRACTORS DECLARATION uCENSE OR ,
DiSp. —Room Air Cond. — L(Q CIosS!►
I hereby affirm�hat I am licensed under provisions of Chopter 9 - REG.nIUMBER .
(commenc��g wiih Seclion 7000)of Division 3 of tha Business power Apparafus 8 large Applionces DISTRICT NO. PROCESSED�Y Q
and ProFessions Code,and my license is in full force ond effec�.
/� ��(�.� $ize 8 Type HP,KW,KVA,or KVAR 2r- O
License Nomber��y���� Lic.ClassS�� � Up to 1 Ind. FINAL
�'T^�I�� y.J�cj �DO Over 1 fo 10 Ind. DATE �. . VAIIDATION. . �
Contracto�� � Date �d Over 10 m 50 IncL . O �
aFINAL
I am exempt�nder Sec. Over 50 to 100 Inc. BY W
8.8P.C.ior ihis reason Over 100 , n-
� Services,Sw6d.,MGC 8 Panel6oards � � - - �
Date: �' rj z
0-200 Amp.Under 600 V
Signoiure ' 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 5W V �
Exemption for Reg.Ma�ni.Elect.
SINGLE FAMRY �-�c�'4�
Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION . � �' • • • e? �
I hereby affirm Ihot 1 am exempt from the Conhodoi s License Sign with One Branch Circuit << "
Low for thr.fallowin nenn f$nc�inn 7p31.5, Posin?ss^.^.d Addi�ionol Siqn Bronth Cireuils _ .
�rr � • •���,i��) -
Professions Code): �
❑I,as owner of the property,will do fhe work and the Misc.Conduiis 8 Condudors ' °,'�7•n�T
srroctore is not in�ended or oifered for sale Section 7044, . Other�See Complete Fee Schedule� , .
Business ond Professions Code). ( � Q�,��—R�
CONSTRUCTION IENDING AGENCY
I hereby affirm ihot there is a conslroclion lending agency for . � _
the performance of Ihe work for whith fhis permit is issued �. PERMIT FEE (Sub-Total) ,�
(Sec.3097,Civ.C.). . -
� PLAN CHECKING FEE
Lender's Name � -
PERMIT ISSUING FEE O
lender's Address TpTAI iEE Z�� �
I tertify tha�I have read�his opplico�ion and sta�e ihat�he ,
above informo�ion is mrrect.I agree to mmply with all Coun�y �
ordinances and S�a�e laws reguloting Elecfrital wiring,ond ' .
hereby thorize representatives oi this Co�nfy to enter�pan
the o e-meM'/ned property(or inspection purposes. � ' _ SEE REVERSE FOR EXPLANATORY LANGUAGE
7�� . . Os
Signaro e of Permi e Date �
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