HomeMy WebLinkAbout1256A (6) WORKERS'COMPENSATIONDECLARATION 76A663 �o�e� qpp��CATION FOR ELEGTRICAL PERMIT � ,
I hereby affirm that 1 have a certifitafe of consenl 10 self CE�8�6(' �
insure,or a certifitate of Workers'Compensation Insuranca, COUNTY OF LO$ANGELES BUILDING AND SAFETY
o r a c e r l i f i e d c o p y I h e r e o f/t S e c 3 8 0 0,L o b.C.)
P❑oliCy N����Lmpany ��C/�I G GOM� FOR APPLICANT TO i1LL IN !OB
Certified copy is hereby fumished. New Residential Bldgs.8 P I EACH NO. FEE E+DDRE55
� Certifiad copy is filed with fhe co�nly buiiding inspec- �g 2-Family,Sq.Ft. l��/ S — E LOCALITY y
NEAREST
tion deparlmenl. � Mulfi•family Sq.Ft. — . • ��.
+� .�^ �}.yy/�/�)� � cRoss sr. r d �h n
Date /'.�r�-n/ Appliconf L/GVl9Q �� �Residenlial Swimming Pools � OWNER OR
FIRM NAME . C/ /� �.
CERTIFICATE OF EXEMPTION FROM WORKERS'' � I � � � � � hwit
Ou�lets;Rec__Light $w.
� '� COMPENSATION INSURANCE �� � First 20 ADDRESS T6(STi V P
(Thi�s.cfion n«d no�6.compl.e�d if th�work lnvolv�d by Totol No.�_ Addi�ional CITY Tel.No.� 3
the p�rmN I�for ona hundrad dollor�(5100)or lass.) ,
I certify fhat in the pe�formance of ihe work for�wh(ch this � . pppNj�C�H�K �
parmil is issoed,I sha�l nof employ any person in any monner
so as to become subjeU lo the Workers'Compensotian Laws. Lighting Fiztvres, First 20 ADDRESS � � ���
� - � � ' To�al No. Add�lional .
Date °PPlicant : ... � CI1Y� Tel.No.
NOTICE TO APPLICANT: If, after moking Ihis Cer�ifimte of fized Appliances Not Over I HP PEpMIT .
Exemption,�you should become subjec� to the Workeri Range_Heater_D.W._ � APPLiCaM .S
Compenwtion provis�ons of the Lobor Code,yoo must forih• Oven _Dryer —W.M._ , ADDRESS � 6 ��.���
with comply with such provisions�or this permit shall be Top _FAU —W.H.—
deemed revoked. � � � � � � �� � � "' CIN . �Tel.Na. �
� � � LICENSED CONTRACTORS DECIARATION . Hood _Fan _Other� - �
I hereby offirm thaf I am licensad vnder p�ovisions of Chapter 9 ��Disp. —Room Air Cond. — � LICENSE OR
�� �� � �� REG.NUMBER 6 CIosS.G-
(commencing with Section 7000)of Division 3 of the Business r � ne�' DISTRICT NO. PROCESSE�BY
ond Professions Code,and my litense is in full force nnd effect. o er p arat s arge pliances }
�� _ Size 8 Type HP,KW,KVA,or KVAR� � 0
license Number Lic.Class �- Up to 1 Incl. � FINAL / � V .
� � Over I to 10 Ind. DATE /Zl;/(�� VALIDATION 0
ConlroUor � Date Over 10 l0 50 IncL � � V
❑ FINAL
I am exempt under Sec. Ove�50 to 100 Inc 8Y a
8.8P.C.for this reason Over 100 ' v�
� ... Services,Swbd.,MCC 8 Panelboords � ► � � �� 2.�l 5 A ?
�Ome: 0-200 Amp.Under 600 V � ' �
Signolure � 201•1000 Amp.Under 600 V � - � � � � � ,� �2
a - Over 1000 Amp.or Over 60p V . . � • •��i 2�1 .
Exemption fo�Reg.Moint.Elecl.
- SINGLE FAMIIY Temp.Power Pote 8 Appurtenances • • •�6.�4� � ��
HOME OWNER-BURDER DECLARATION Sign with One Bronch Cirwit
I hereby eflirm that I am exempt from the CoMractor's License ���`)-P'7
Law for fhe following reason(Section 7031.5,Business and - Arkiitionnl Siqn Rrnnch Cirrui�x � ,
Professions Code): '
❑ I,os owner of ihe properfy,will do the work and ihe Misc:Conduits 8 Conduc�o�s - � � � � - �,
strocture is not intended or offered for sale(Sedion D�her(See Compiete Fee Schedule)_ ►
7044,Business ond Professions CodeJ. � �� �
CONSTRUCTION LENDING AGENCY �� . . .
I hereby affirm that there is a con:truUion lending agency for �
the performante of ihe work for which this permit is issued PERMIT FEE� . � (Sub-Totol) . .. . � .., , , �
�Sec.3097,Civ.C.). � , ,
� � . - -- PLAN CHECKING FEE --� � .
Lender's Nama � �
� . PERMIT ISSUING FEE
lender's Address � ' - � � � � �
I cerliiy that I have read tMis opplication ond state that the . TOTAL FEE �
� above informolion is correct.I agree lo comply with oll Counly . �� - �
o�dinontes ond S1ote lows reguloting Electrical wiring,and - � .
hereby authorize representaHves of this Coun�y to enter upon � �� � � � � " � � � � � � �
the obove-mentioned pr erty for inspeciion purposes. SEE REVERSE FOR EXPIANATORY IANGUAGE
7--30—�� ..
ignatore of Perminee Date � � . - �
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