HomeMy WebLinkAbout1219A (6) � WORKERS'COMPENSATIONOECLARATION 76A683 +oie+ APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affirm ihat 1 have a certificate ot consent to self insure, cE-BosG
oP a cerlificate of 1'Jorkers'Compensation Insurance,or a certified . COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy lhere0f..(�S�e�c�.y380(0�,(L�eb.C.1„�q �� _ /
Policy No.(L�L7--L 1-7�Comrsar�l S �+-�P �U^�( FOR APPLICANT TO FlLL IN - . JOB / / /
� EACH NO. �E ADORE55 (jj }p �� �l�l�Y/� 00l�
Certificd copy is hereby furnished. New Residential Bldgs.&Pools �
❑ � 182-Famii Ft. � — 5 LOCALITY �(A,,.�oR[ tJ�/
�Certified copy is liled with the cwnty building insOeCtion Y��� _
depar�ment. . . Multi-f�mily^,�.Ft. NEAREST
CROSS ST.
.D�te 1' I�' i�,. �lT Appli� � �- ReSidC'nti�l SWimming POOIS FRM NfAME �'� `� /V
. � CERTIFICATE OF EXEMPTION Ff70M WORKERS' p�tlets:Rec� ght_Sw.� MAIL �
� � COMPENSATIONINSURANCE - - . _ ..3_ O noor;ess
� lThis settion need not 6e compieled II the work Involved by[he � Fiist 20 CITY � Tel.No.
permit Is(or one hundred dollars($100)or�ess.) Total No._�_ A/d�ditional .
I certiFy tha[in tho periormance of the,vrork for which this�permit � N ti..J�X ... ,. . pPp�ICANT K �
is issufd,I shall not empioy arry person in arry manner so a3 t0 '�
become subject to the Ylorkers Compensation laws. L'gMin9 Fixtures First 20 ADDRE55 ..
� � Total No. Additionat CITY - . Tel.No.
Date Applitant Fixed Appliances Not Over 1 HP
rer�nniT ',,,L ..L
NOTICE TD APPLICANT: It, alter making this Certiticate of A��iCAM�W I ��J'� �d'Il�.v�
Exemption,you should become subject to the Workers'Compensafron Range_Heafer_ D W. _ � �
,provisions'of the Labor Cade,you must forthwith comply with such � Oven_Oryer_W.M._ - � ADDRESS �/n��.-e��/ �
provisions or this permit sh�i1 be deemetl rewked. Top _FAU _ W.H._ , _ . CITY �� ����� � Tel.No.-� _�
LICENSED COMRACTORS DECLARATION Hood_ Fan _ Other_
I hereby atfirm th0t I am licensed under provisions of Chapter 9 LICENSE OR ,
(commencing wilh Section 7000)of Division 3 oF ihe Business antl Disp. —Room Air Cond. _ . Ciass. .
REG.NUMBER
Pf01@SS�Of15 GOdC,�nd my IiCenSe ts in lull fOrCC 3nd B1feCt. pp�pf App3ratU5 8 Large Appliances D�STRICT NO. �� PP EO�S$�D BV n
\(\7\ \\ �
SizB 8 Type HP,KW,KVA,or KVAR � � L��- V
License Number tl� ����7 Lic.Class� � Up ro 1 Incl.- �� - - FINAL '9 � � �
Over 7 M t0lncl. DATE n y �
VAUDATON O
�ContradoruL T� 'r[t!•c"}--Date'�4� ' "" � Over 10 to 501nc1. � � FINAL � (/ o U
❑ I am exempt under Sec. Over 50 to 1001nc. BY . , . W
a
B.SP.C.for this reason Over 700 t/�
� . � Services,Swbd.,MCC 8 Parielboards Z
oate:—.r_3� (� 7 0•200 Amp.Under 600 V ►
¢'� /! 201--1000 Amp.Under 600 V - -
-� �� � �- � Over 1000 Amp.ar Wer 600 V
Eremption for Reg.Maint Elect.
� SINGLE FAMILY � - � Temp.Power Pole 8 Appurtenances
HOME 01YNER-�UILDER DECLARATION Siqn with One Branch Circuit z� 2�.9�
I hereby 2Flirm that I am exempt from the Cont2ctor's LiCense Law ��� ��.J �
� tar[he tollowing rcason(Section 7031.5,Business and i-roiessions - p--""""- �_"°=h C�m.���s _ _ _ _ � .• �
Code): �• •2
� Misa Conduits&Conductors � � • � �5 Q
❑ I,as owner of the property,wiil do the wo�k and the structura Other�See Complete Fee Schedule)_
is not iMended or otfered for sale(Section 7044,Business ►
and Protessions Code). • 1 3 5 0�
CONSTRUCTION LENDING AGENCV � - � - - � - O H�9—S H -
I hereby affirm tha[there is a construction terding agency 1or the
perlormance of the work for which this permit is issuetl(Sec.3097. . pERMR FEE - - --- - (Sub-7otary . .. . . . .
Civ.C.).
.. PLAN CHECKING FEE . .. _. . -
Lender's Name O O . , ,
PERMIT ISSUING FEE '
Lender's Address ���
I certify that I have read this application antl state that the abwe TOTAL FEE
info�matian is corred.I agree to comply wilh all County ordinantes ' .
and State laws rec�ulating Elecirical wiring,and hereby authorize .
representatives of this County to enter upon the above-menfioned � �" "- " � " � " � � . �
pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . _ _ . .
/ _
ynalure of Permntee •�ate
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