HomeMy WebLinkAbout1253A (6) WORKERS'COMPENSATION DECIARATION �r 76Aa63 ioiBl '
I hereby offirm fhot I have a cedificate of consent to self �E�� APPUCATION FOR ELECTRICAL PERMIT �
ins�re,or a certilicaie o(Workers'Compensation Insurance, COUNTY OF LOS ANGELES BU�LDING AND SAFETY
or a certilied copy Ihereof Sec.3800,Lob.C.) � � O T�
+�iO���'9 J
P❑ol�iCy No.(�'�'lLyZ� mpony + I � FOR APPLIUNT TO Flll IN JOB �
Cerfified copy is hereby lurnished. , . New Residential 81dgs.8 Paols , EnCH NO. FEE A���
� Cerlified copy is filed with Ihe tounty b�ilding inspec• 1 8 2-Family,Sq.Ft. �73� E — S LOCALITY
tion department. , Mul�i-family Sq.Fi. — NEAREST
�T [� Rr.sidenfial5wimmin Pools
� CROSS 5T. ,S � �r
Date 7 3d'�/ APPIicaM�A� U. ����_ 9 OWNEROR
CERTIFICATE OF EXEMPTION FROM WORKERS' ' , � �� FIRM NM4E /` S �
� � COMPENSAT�ON INSURANCE Outlets:Rec�LigM�Sw.� DDRE55�
�f First 20 S kS '
(Thi���sct�on naad no1 b�eomp�of�d li fh�wo�k Involwd by Total No.___[�_� �� CITY. Tel.No
th�permit it For ona hundr�d doilan(SI00)or la�s.) Additional � -Q
PU1N CHECK
. I cerfify Ihat in ihe performance of the work(or whith Ihis � APPLICANT '
permit is issued,I shall not employ any person in ony manner ' �
so as io become subject to the Woikers'Compensotion tows, Lighling Fiztures �Firsl 20 � ADDRESS
� . . . . . Totol No. Additional � �
. Date � °PPlicont .. ..'.. CIN Tel.No.
NOiICE TO APPIICAN7: If,�affer moking ihis Cerlificate of Fixed Appliances Not Over 1 HP PERMIT (+.f `�
Ezemp�lon, you should become�subject to the Workeri Range_Heoter_D.W.— APPIICANT v' /r�,
Compensation pravisions o(tha lobor Code,yoo must forlh• Oven _�ryar _W.M.— � ADORE55 � � �� .�
wi�h comply wi�h wch provisions or �his pe�mit shall be Top _FAU —W.H.— � p�p� . '
daemed revoked. � � � � Hood _Fan _Other.� CITY � � Tel.No737 p a
LICENSED CONTRACTORS DECLARATION . �iCENS�Og
Disp. Room Air Cond. — � .. Uoss.
I hereby affirm thof I om licensed under provisions of Chopler 9 p.,�•� � REG.NUMBER oZ. ��. . .
commencin with Section 7000 of Division 3 of the Business �� �f � � r ��AC/�
( 9 J DISTRICT NO. PROCESSED BY
P6w� A profus Large Applionces
ond Professions Code,and my license is in full forte and effecL -� �� /� � � �r' .. a
. Size 8 Typa HP,KW,KVA,or KVAR- l� I,f- � '
License Number Lit.Closs � Up to 1�Incl. � � FINAL � � � � V
� . Over I fo 101nd. �'�'� �Z�1 1/j� VAUDATION Q
Contracior Da�e Over 10�0 50 Incl. FINAL ~
❑ I am exempl ander Sec Over 50 10 700 Int.. BY � �
B.&P.C.for this reasan Over 100� Z
� � Date: � �� Servicas;Sw6d.,MCC 8 Panelboords , . �� .�� 2�.3� .
0-200 Amp.Under 600 V �� �2 �,
Signo�ure - 201-1000 Amp,Under 600 V �� �� � � � � � � �
a . Over 1000 Amp.or Over 600 V �� e •Fj��.2 Q ��
Exemplian for Reg.MoinL Elect - �- � - � - . . , .
SINGIE FAMILY � • • •�b��l= '
Temp.Power Pole 8 Appurtenances �
HOME OWNER-BUItDER DECIARATION Sign with One Branch Gircuit �G S O F-a 7 �
I hereby affirm Iha1 I om exempt{rom the CoMrador's License . Addi�ionnl$ign B.onth Chcvi!s �
Law for Ihe tollowing reason(Seclion 7031.5,Business and -� � - �� � �� �.
Professions Code): '
� - M,sc:Condui�s 8 Condoctors '�� � � ��
I,as owner af the proper�y,will do Ihe work and the ' . ,
shuclure is nol intended o�oftered for sole(Sedion Other(See Comple�e Fee Schedole)— , -
704E,Business ond Professians Code�. � ►-���� � � � �� ' � � � �.
CONSTRUCTION IENDING AGENCY . . ._, .. _ , _,
I hareby af(irm that there is a consfrucfion lending agency for �
the perfo�monce of ihe work for which ihis permil is issued pERMIT FEE�� � � � ��� -��� � (Sub•Total) . . .. ._.. . ..,
(Sec.3097,Civ.C.). � � . - .
PIAN CHECKING PEE � � � � .. , . . �
lendei s Name � � � ��
- . PERMIT ISSUING FEE Q � . �
lender's Address � � � � '� �
�cerlify�hat I have read Ihis applicalion and slate Ihaf the TOTAL FEE d �
obove iniormotion is correct.I agree to comply with all County � � � �� -- - �� � '
ordinantes and Stole laws regulaling Electrical wiring,ond �
he�eby auihorize representatives of ihis County�o enter opon � � -� � � � � � , � . � � � � � � � � -
ihe obove-menrtoned property for inspection purpases. SEE REVERSE FOR EXPLANATORY IANGUAGE
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