HomeMy WebLinkAbout1038A (5) WORKERS'COMPENSATIONDECLARATION � �6a663 ,o�a, APPLiCATION FOR ELECTRICAL PERMIT � ^ '
I by afiirm fhat I have a certifimte of tonseN 10 seli CE-ea6G � j
su or a cert'rfimre oi Workers'Compensation Insurance, COUNTY OF l05 ANGELES BUILDING AND SAFETY
c rtified copy�hereof(Sec.3800,Lab.C.)
oli[ No. - Com an FOR APPLICANT TO FIIL IN JOB h n 'l� f
Certified topy is hereby fornished. New ResideMiol Bldgs.8 Pools EACH NO. FEE � ADDRE55 �/O� ��y� /���< <� �
Certified copy is filed w Ih coonty building inspet- � 1 8 2-Family,Sq.FL S — f LOCALITY ,,U. NLG � �
fion d en�. � Mulli-famil S Ft. — NEAREST q-. ' �
f� � � C(� �(a(LZ'/��(,�� � ResideMialSwimmingPaols \\C� ' '..- OWNEROR��y��l],y�.�� /-��1 '
Date Applicont � FIRMNAME /r�b/�7t�V ZL?fr9 .
� � CERTIFICATE OF EXEMPTION FRO WORKERS' Outlets:Rec_Li9h�_$w._ . ��� �� /,, �T
� COMPENSATION INSURANCE '. ADDRE55 U�I�E L /.1�� .
Thii��ctten nNd nof 6�com �st�d if�h�work involv�d b First 20 �
� P Y . Totol No. Additional CITY G� /qi(�E(� Tel.N . GjpS ZD �
�ha permit is for one hundnd dellaa(5100)or lafs.) ' .
I cerfify Ihat in Ihe prrlormance of Ihe work for which�his ; � APPLICANTK -
petmit is issoed,I shall not employ any persan in any manner �
so as to betome subject to ihe Workars'Compensation laws. . lighting Fixfures First ZO � ADDRE55
� � Addilional �
Toial No. CITY - Tel.No.
Dote °Pp�icanl Fized Appliances Nol Over 1 HP PERMii ���
NOTICE TO APPLICANT: II, ofler making this Cer�ifim�e of ! qpplIG4NT •��. LCi�� I�� -
Eaemp�ion, you should become subjecf to �he Worken' Range_Heote�_D.W._ �.
Campensation provisians of fhe Lohor Code,you must forth- Oven _Dryer _W.M._ I ADDRES$ ?��L�"� t �d(/�,�Eu'C'%� ��
with comply ilh such provisions or Ihis permil sholl be Top _FAU —W.H:— � . �
deamed revaked. . CITY Tel.No. U
UCENSED CONTRACTORS DECLARATION� Hood _Fan _Other_ ����� �z3"L�+ 2 �
LICFNSE OR /(' �/
I hereby offirm thol I am licensed�nder provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER Zfe'7 ✓�-�Y' Class. C�.�/ }.
(tommencing with Secrion 7000)of Division 3 of the B�siness power Apparol�s 8 Large Applipnces DISTRICT NO. PROCE BY O:
�ond Professione Code,and my license is in full force and eHect�-�� � � 4 U ;
, Size&Type HP,KW,KVA,or KVAR� �•� ,
license Number Lic.Closs' � 7/W Up to 1 Ind, •� Z FINAL /' � �
� Over 1 to 70 Incl. DATE /{��ff��jy VALIDATION �
Coniroctor Date � d�' f� .
Over 10 to 50 IncL FINAL W
I om exempl under Set. t�'�°� ver 50 to 100 Int. BY N�
B.BP.C.for�his reoson O9ef�� � � Z �
Dare: Sarvites,Swbd.,MCC 8 Ponelboards j �
. 0-200 Amp.Under 600 V
Signa�ure 201-100D Amp.Under 600 V ,
❑ � � Over 1000 Amp.or Over 600 V , _ . �1 O�8� ;
Ezemption for Reg.Maint.Elect. ��
� SINGLE FAMILY � #J• • • •��2 I
HOME OWNER-BUIIDER DECLARATION , Temp.Power Pole 8 Apportenances ,,
Sign wirh One Bronch Circuit -� �
I hereby offirm�ha1 I om e.empt from Ihe Contrac�or's Ltcensa ' p��itional Sign Eranch Ckcuits � • • � E{5 U '
Low fo�rhe following reason(Section 7031.5, 8usiness and � , . '
Professions Code): � � �
� I Misc.Conduits&Condoctors ��• • � �5�'�_'
I,as owner of 1he property,will do ihe work and the f I 21 5-£i 6 .
shucture is not inlended or offerad for sole(Seciion I Orhe�(See Camplele Fee Schedule)_ , . . � �
7044,Bosiness and Professions Code). �
CONSTRUCTION LENDWG AGENCY {- � . i
I hereby affirm�hat there is a construdion lending ogency for I � I
the pe�iormance of ihe work for whith�his permit is issoed � PERMIT FEE � � (Sub•Tolo1) �
(Sec.3097,Civ.C.). �
PLAN CHECKING FEE .
Lendei 5 Nome �
PERMIT ISSUING FEE � D
(ender's Address 1 . �a � �
I certify thot I have reod fhis opplicafion and sfate lhot Ihe ' TOTAL FEE �r . � �
above information is mrrect.I og�ae�o mmply with all County
ordinontes ond S�ate laws regulating EleUricol wiring,and �. . . � .
h eby outhorize representotives of this County fo enler vpon , , �
� above-me r ned ropery for inspectton�purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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