HomeMy WebLinkAbout1254A (6) WORKERS'COMPENSATIONDECLARATION �� 76A667 �10/81 qpp��CATION FOR ELECTRICAL PERMIT � �
I heieby offirm�hat I have a tertifimte of consenl to self CE'eo6G
insure,or a ceruficate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES � BUILDING AND SAFETY
or o ceritfled copy thereof�Sec..3800,Lab�C.) ...
POolicy N�✓P//.s3�Dmpany � ' FOR APVIICANT TO FILL IN JOB
Ceriified copy is hereby furnished. New Resfdential Bldgs.8 Pools EnCH NO. FEE A�RE55 �
� Cerlified copy is filed wilh the coonty building inspec- 1 8 2-Fomily,Sq.R.�7?l s O — E �aA��iY �
NEAREST
� tion deportmenL� (� Multi•family Sq.FL � CROSS ST. i�.S �
Da�e 7 30_�7 Applican�i� a••)r ��, Residential$wimming Pools OWNER OR
F�RM NAME
� CERTIFICATE OF E%EMPTION FROM WORKERS' � / � � � Mnu
COMPENSATION WSURANCE Outlets:Rec LtgM_r_Sw. . S � AODRE55 � VC
Th�s��cfion n��d not b�com I�Hd li fh�werk involv�d 6 �First 20 �
� P Y Total No.�. Additional � � � CITY � Tel.No. ���
Ih�permtl is lor ona hundrod dollm�(5100)or lass.) � P1t�N CHECK �
I certffy tho�in the parformonce o(Ihe work for which this � � APPIICANT
parmif is issued,I shall no1 employ ony persan in any manner �
so as lo become subject to the Workers'Compensation Laws. Lighting Fixlures . First 20 �� ADDRESS � � �
� � � � � Total No. Additionol
Do�e /+pplicoM " � CITY Tal.No.
NOTICE TO APPIICANT: If, after�moking this Certificote of Fized Appllonces Not Over 1 HP pppMj��p,NT !� �
Ezemption, you should 6ecome subject �o Ihe�Worke�s' Range_Heoter_D.W,— S`S U �. .
Compensation provisions of the Lo6or Code,you must farlh- Oven _Dryer _W.M._ ADDRE55 � .Q �
wilh comply with such provisions or ihis permil shall be Top —FAU —W.H.—
deamed revoked. � �� � � � � CITY L' �� Tal.No. � �d �
LICENSED CONTRACTORS DECLARATION . Hood _Fan _Other...I� .
LICENSE OR
I hereby oHi�m�hot I om licensed under provisions of Chopter 9 Disp. —Room Air Cond. — REG.NUnneER Class.C- 0 �
� (mmmencing wilh Sedion 7000)of Division 3 of Ihe Bosiness ��r/��L� �Odl Q/��.Ae/� DISTRICT NO.� PROCESSED BY -
ond Rofessions Code,ond my license is in full force ond affed. ower poratus 8 Large pp�ances ^�' „ _ �
. . Slze 8 Type HP,KW,KVA,or KVAR� v O
litense Number Lic.Ciass �� Up l0 1 Ind. � � fINAL � � � � V �
Contractor Daie Over 1�o IO lnd. DATE (Lt�l ft7 VAIiDATION � 1
a Over 10 to 50 Incl. F- i
FINAL
I am ezempl under Sec. Over 50 fo 100 Inc. BY � uV+
B.BP.C.for this reoson Over 100 � y '
_ . . . . Services,Swbd.�,MCC 8 Panelboards ' � � - �� - � _ ��,2,5�1� ?
� Date: 0-200 AmP.Under h00 V � � - i{• • •`z �
SignaNre � 201-1000 Amp.Under 600 V ' - � � � � -
� OOver 1000 Amp.or Over 600 V � I • �R Fi 2�! �
Exemption for Reg.Mainl.EIecL � �
� � SINGLE FAMILY Temp.Power Pole 8 Appunenonces • •� g�2�y �
HOME OWNER-BUILDER DECIARATION Sign with One 8�anth Circuil � � O�O Jr-`3 I
I hereby a((irm that I am eKempt from the Contractor's license paa�,�_„al Sign 9rench Circui!s '
Law for ihe following reason(Sec�lon 7031.5,Business and � � � - � � -
Prafessions Code):
❑ I,as owner of 1he property,will do Ihe work and the Mist.Conduits 8 ConduUors '�� � ..
sfructure is not iMended or offered for sale(Sedion . Other(See Complete Fee Schedule)_ , � �
' 7044,Business and Professions Code). , �
CONSTRUCTION IENDING AGENCY -._ ...
I hereby afiirm thot there is a mnstrudion lending ogency for �
the performance of the work for which rhts permir is Issued PERMIT FEE - -- ��-�� � (Su6-Toral) � - -.. . � .. .
(Sec.3097.Civ.C.). � � . . ,
. � � - PLANCHECKINGFEE--- -� � � � �� -� - _ . � _
lender's Name
� � PERMIT ISSUIN6 FEE . . . �
Lender's Address � ` ^ � � �� � � � �
I certify Ihal I have reod this opplicotion ond stoie lhat the TOTAL FEE � 6�0( .. _ . . . . , .
obove informofion is torrecl.I agree 10 compiy with all County
ordinonces and Stote laws�egubting EleUricol wiring,and , � '
hereby authorize representatives of this County to en�er upon � � � � ��� � � . " � � � � �� � �� � � �-
�he obove-mentioned p�operly for inspecrion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,��/ ��: �;C 7 30--�"> . .
Signature of Fermittee Date . .
✓
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