HomeMy WebLinkAbout1354A (13) �EKs'COh1PENSATIONDECLARATION '� 76A663 ppp��CATION FOR ELECTRICAL PERMIT
� ' � CE�806G f2-80) �
�m that 1 have a certiticate of consent to xlf COUNTY OF LOS ANGELES BUILDING AND SAFETY \
rtificate ot Workers'Compensation Insurance,or .
, •ihereot(Sec.3800,Lab.C) r� � �
� -•I SR 1 ����I�/� FOR APPLICANT TO FILL IN JOB � /
_y No. Company �✓� EACH NO. FEE ADDRE55 •/S (fX���/+/ �,f'
-�''� - New Residential Bldgs.&Pools
� CertiFed copy is herehy furnished. � � .i&2•Family,Sq,Ft. S — 5 LOCALITY /q fN� '
Multi-family$q,Ft. — NEA T
� Certified copy is fled with ihe cnunty bullding Inspection CROSS ST O/�,r i�• s'
department. � Residential Swimming Pools pWNER OR /J .
� 9 FIRM NAME �(�!� C.-�1G���
Date Appficant Outlets:Rec.y�Light�Sw� � ADDRE55 �ieJ� �
First 20
Cl3RTIFICATG OC EXEh1PTION fROM WORKLRS' Total No.� Additional CITV �� � Tai No. � (�'
, C01�1PENSATION INSURANCF. P�AN CHECK �'
APPLICANT a'
•(This section need not be compieted if fhe work involved � ��
by the permit is for one hundred dollars (SI00)or less.) Lighting Fixtur� First 20 qoDRESS � V�
Total No. Additional � ,
1 certify th�t in the pertormance of the work for which this CITY Tel No. O
ermit is issued,1 shall not em In an Fized Appliances Not Over 1 HP �
p p y y person in any manner PERMIT
so as to become subject to the tVorkers'Compensation Laws. Range_Heater_�.W. . AaauCaNT `�L �'� �f//�E �W
OVen�_DryBf_W.M._ ADDRESS���Gf�jA+��i;�J �
fall
Date Applicant Top �_FAU _W.H._ Z
� Hood_Fan _Other_ CITV � , Tel No.� /,Z
NOTICIi TO APPLiCANT:If,atter making ihis Certificate of Disp. _Room Air Cond� LICEN E OR y� �/ �
Exemption, ynu should become subject to the WorAers' REG.NUMBERJ����Y Class .
CompGn58tI0f1 provisions of lhe Labor Code,you must forth• ppwer Apparatus&Large Appiiances DISTRICT NO. PROCES ED BV '�
with comply with such provisions or this permit shal! 6e . .. .
deemed revoked. Size&Type HP,KW,KVA,or KVAR /O QA�� ��
Up to 1 Incl,
Over 1 to 10 Incl. F�NAL � .
LTCENSEDCONTRACTORS DECLARATION DA7E �/��/�� VALIDATION ;
er 10 to 50 Inel. �
I hereby affirm that I am licensed under pmvisions of Chaptcr Over 50 to 100 Inc. FINAL. �
BV.
9 (commencing with Section 7000)ot Division 3 of[he Ausi• � Over 100 r�/�� t.(p`p,�`� �
ness and Professions Code,end my Iicense is in full force and �
etfect. � Services �
�y'//t�G/ f� 0-200 Amp.Under 600 V �
icense Numbe /� ,L�/ic.Class 2a�.�pp0 Amp.Under 600 V -
�t�a�����~�) `�E��bst�e ��7 Over 7000 Amp,ar Over 600 V , .
HOb1E OWNF.R-AUII,DER DECLARATION Tem Pawer Pole& �
p. Appurtenances
•by affirm ihat I am exempt Crom the Contrncror's Sign with One Branch Cirtuf[ � _ �
+ Law fn�thP f�i�ow���.P��,.� co�r;�� 7n��c a�..�. Additional Sigo Brench Circuits , -
. .C-""-" '-.- .
1 Prafessions Code): �1 3 5.4 A �
Misc.Conduits&Conductors .
t oH•ner af the property,wiil do�the�votk and the Other(See Complete Fee Sehedule)— �� ��.� � � �
ture is nat�intended or ofkred for sale (Scction � 2
� Husiness and Protessions Code). � •� ' .
CONSTRUCTION LENDINC AOENCY � � • • � �J,�9O
'firm that there is a construction lending agency �
�ormance of Ihe work for which this permit is . ,� • • � �9 Q=
PERMIT FEE �(Sub-Total) "
av�.c��.c.). ' G 1,2 7—8 2
' . PLAN CHECKING FEE (Dne•Fourth Permit Fee)
. ts PERMIT ISSUING FEE � �_J
�ave read this application and state Ihat the TOTAL FEE
' t5 correct.I agree to complY�+'��h all County `� �� 1 1
tate Is«s regulating Electrical wiring, snd � 1 1
•pr�sentati�•es of this Coun[y to entrr upon
1 pr�ty r inspection purpose�.� SFG'REVGRSB 1'OR EXPLANATORY LANGUAGF.
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