HomeMy WebLinkAbout1332A WORKERS'COMPENSATION DECLARATION 76A663 �0,8,� - qppLICATION FOR ELECTRICAL PERMIT {�
! CE-BOBG
I hereby alfirm that I havC a Cer�ifiCetB ot Con52nt 10 Self InSUre, '
w a certiticate ot workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY L�
copy thereol�Sec.380/0.Lab.C. �.j/� y��,,,�1{ �//�����
plp��Cy (1� �ylL�Q�m�y�yV�//�G^�G u'Y� FOR APPLICANT TD FILL IN� � - � JOB c
Certified copy is hereby fumished. New Residential Bldgs.&Poo�s EACH NO. FEE Aoo�ess p�5. -e , /�y'
� �Cer�ified copy is�filed with ihe cwnty buildirg inspection 1 S 2•Family,$q.Ft. S — S LOCALRY �j
� department. Multi-famity Sp.FL — NenaEsi ,
�� � - �� , R=sid=ntizl Swimm' Pools �- .__ caOSS sr.
DZte AppliCant �P� ,a� � F�RMNAME "/ ///
CERTIFICATE OF EXEMPTION FFtO WORKERS' puttets:Rec_L'ght_Sw.— MA��
. . COMPENSATIONINSURANCE nooaess
(Thls sectlon need not 6e compteted it the work involved by the Flrst 20 � �
permit(s tor one hundred dollars($100)or less.)
Tatal No. Addiiional CITY �Tet.No. �
I certify that in the perlormance of the work for which this permit PUN CHECK .
i5 ISSU2d,I 5hatl not employ any persOfl ifl 8ny fflZnflef 50 85 t0 A�'PLICAM
become sab�ect to the Workers'Compensation Laws. L'ghting Fixtures First 20 ADDRE55 . . .
-� . � . Total No. �itional _ . CITY � � Tel.No.
� Date Applicant Fzed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, aftcr making this CertiFicate of f'ERMii )
Exempti0n,yoU should beCome SUbjeCt to the Workers'Compensation Ran9e— Heater_D.W. _ APPLICAM -
provisians of the Labor CoAe,you musi forthwilh comply wilh such Oven_ Dryer_W.M._ - - AD�RESS� -� o�y� ,�
,provisions or this permit shall be deemed rewked. Top _ FAU _W.H._ C
LICENSED GONTRAC70RS DECLARATION Fbod_ Fan _Other_ ��N -P/� C �'NO���"t'�/
I hereby affirm Ihat I am licensed under provisions O1 Chapief 9 D�Sp. —ROOrtI Aif COf1d. — LICENSE OR , � p /?`.� ��gs n ,i(
(commencing with Section 7000)af Division 3 of the Business and REG.NUMeER O ��. V
Rofessions Code,aM my license is in full for�e and effect. � Power Apparatus 8 Large Appliances DISTRICT NO. ESS
License Number �7`! d /7� Lic.Class C /Q Size 8 Type HP,KW,KVA,or KVAR l O O
n Up to 1 Incl. FINAL
�� � ri,�8ate 9�7 0��( Over 1 to 10 Incl. DATE VpLIDATtON O
Contractor LU" ' Ovei�10 to 50 Incl. FINAL U
I am exemp under Sec. . Over 50 to 700 Inc. gy • a
BSP.C.for this reason Over 700 � N
- Services,Swbd.,MCC S Panelboards 7� � � - � - �
- � Date: 0-200 Amp.Urder 600 V �j v
Signature 201-1000 Amp.Urder 600 V�� � � �� - � ^� �
P
❑ � �- � � � Over 10D0 Amp.or Over 600 V "
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECIARATION Sign with One Branch Circuit � - � � - �- � �
I here6y zffirm that I am exempt from the Conhactor's License Law AAtlitional Sion Brench Circvits
'_r L`a -,,;;,v�ng rason(S�,an'��t.5,Cus;F�s and t''c'er;�s - . . . . -- - 1 �J 7J.[A
CotleC,V �
❑ I,as owner of the properry,will do the work and the structure � Misa Conduits 8 Conductvrs - -� � � � 2
• i i• •
is nct intentle0 or offered for 5ate ISection 7044,Business Other(See CAmplete Fee Schedutel_
and Professions Code). � � ��' � �� � �� � ► � � • •3 0 5 0
CONSTRUCTION LENDING AGENCY � � - � - - - - � � - • • •��Q 5 O�
I hereby affrm that there is a construction lending agency for the
performance of the work for which this permi!is issued(Sec.3097, pERMIT FEE es�b-ro�an . ... . �� � . 0 9.0 2—8 8
Civ.CJ.
. PLAN CHECKING FEE �
Lender's Name -
PERMIT ISSUING FEE Q
Lender's Address
I certify that I have rezd this app�kation antl state that the a6ove TOTAL FEE ' '
information is cor2ct.I agree to comply with sll County ordinances - �
. and State laws regulating Electrical wiring,ard hereby aulhorize �
representatives of this County o enter upon Ihe above•mentioned � �� � ' - "� �
pro y for inspection purpo. .
e��w �C� Q-�-�� -
SEE REVEFSE FOR E%PLANATORY LANGUAGE �
igi at e ot F'crmittee Date
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