HomeMy WebLinkAbout1289A WORKERS'COMPENSATION DECLARATION 76A663 ,a�B, qpp��CATION FOR ELECTRICAL PERMIT � �
I hereby off'vm thal I have a cerilRtoie of consent�o self CE-806G .
insure,o�a cernficate of Wo�kers'Compensaiion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY !
orp���(((er�'fied copy�hereof(Sec.3600,Lob.C.) , '
����`�'� Company �N�� FOR APPLICANT TO FILL IN DDRE55 ,70� /v �4�
Certified capy is hereby furnished. New Residential Bldgs.8 f o� EACH NO. FEE
� Cerrified copy is filed with the counly 6uilding inspec- 1 8 2-Family,Sq.F�.� S� — s LOCALITY
t' dep iment. Mul�i-family Sq.Ft. — NEARESr
—� "l�, �_ �R�u 5T.
��� ws ResideMial Swimming Pools OwNER OR
Do�e / Applitanl � �ML� FIRM NAME � Oi�
CERTIFICATE OF EXEMPTION FROM WORKER$' mAa �D �
COMPENSATION INSURANCE Ou�leh:Rec_Light_Sw._ ADDRE55
ThL�edion nNd nef be co�n 4»d;f ih�work involwd b First 20
� o Y Totol No. AdditiOnol CITY Tel.No. I
fhe p�rmtf Is ior one hundred dellen(5100)er Is+s.)
I cert�f that in fhe erformon�e of the work for which this RAnI CHECN
Y P APPLIC{tNT
permi�is issued,I shall nol employ any person in any menner
so as to 6ecome su6jeci to the Workers'Compensa�ion laws. , Li9h�ing Fixtures Firzt 20 ADDRE$$
To�al No. Addiiional
�w,- CITY Tel.No.
Dme eppticont Fiaed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, ofter making this Cerlificote of AaaIICANT� �� �
E.emption, you should 6ecome subjecl fo Ihe Workers' , Range_Heater_D.W._
Compensation prorislons of tha Lobor Code,you must forth- Oven _Dryer _W.M._ ADDRE55 /
wiih comply wiih such provisions or �his permif sholl be Top _FAU _W.H.—
deemad revoked. � CIN� � Tel.No.
LICENSED CONTRACTORS DECIARATION Hood _Fan _O�her_
LICENSE OR p
I hereby afiirm�haf I am licenxd under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER O Class. �b
(commencing wilh Seclion 7000)of Division 3 of Ihe Business power Apparol�s 8 torge Applioncas DISTRICT NO. PROCESSED BY pr�' �
and Professions Code,and my license is in full force and effect. (�
Size 8 Type HP,KW,KVA,or KVAR U
li[ense Number � Lic.CIasS ��D Up ta 1 Incl. FINAI �
���`�� Dote �� a� Over 1 to 10 Incl. DATE �p 1y`� VALIDATION U
Controcto Over 10�o SO Incl. /
❑ FINAL Lcl
I am ezempt under Sec. Over SO to 100 Inc. 8Y O.:
Over 100 N
6.8P.C.for this reason Z
Date: Services,Swbd.,MCC 8 Gonelboards �
0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V .
Over 1000 Amp,or Over 600 V .
�- Exempiion for Reg.MoinL EIecL �
� SINGIE PAMILY . �
HOME OWNER-BUILDER DECIARATION Temp.Power Pole 8 Apportenances �1 2�.9 A
Y F $ign wilh One Branth Cirt�it {f• • . � .2
I F.ereb effirm ihct I am exem t from the Confmctor's license qddilionol Sign Bronch Cirtuifs �
Law for�he following reason(Seciion 7031.5,B�sineu and
Professtons Code): I e•6 6 8 6
❑ I,as owner of the property,will do�he wo�k and the Mist.Conduiis 6 Condudors �
structure is no�intended or otfered for sale(Section O�her(See Complete Fee Schedule)_ , e ° a G 6 8 6 c=.i
7044,Businezs ond Protessions Code). �$2 5�8 6
CONSTRUCTION IEND�NG AGENCY
I hereby a((irm Ihot there is a construction lending ogency for
the performance af the work for which Ihis permit is issued PERMIT FEE (Sub-Tofal) �
(Set.3097,Civ.C.). .
PLAN CHECKING FEE
Lender's Name �
PERMIT ISSUING FEE
lender's Address �
I te��ify fhof I have read�his applicotion and sfa�e iha�the TOTAL FEE �
above inlormation is correct.1 ogreo�o comply wifh oll Coun�y
ordinonces and S�o�e laws reguloiing Electritol wiring,ond
hereby authorize representatives ot�his Coonty to enter upon
ih bave-mentioned properry for inspeciion pucpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
� ���"
SignoWre cf Permittee Da�e
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