HomeMy WebLinkAbout0625A (4) . WORKERS'COMPENSATIONDECLARATION �eA663 � APPLICATION FOR ELECTRICAL PERMIT �
CE806G(2�80)
t hereby aftirm that I heve a certificate ot consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or G�xa$�-�(1
a certified copy thereof(Set.3800,Leb.C.)
Policy,��80-6249�,�mpe�YFreemnt Indemni ty FOR AVGLICANT TO F�LL IN � ADDRESS 901 Golden Springs DT,'.
. . New Residential Bldgs.&Pools EACH nlo. FEE
� Cer[ifed coyy is hereby futnished. . �$2.Family,5q.Ft. S — S LOCALITY Z
- Multi-family Sq.Ft. — Ea 7
� Certified rnpy is filed with the county building inspection Residential Swlmming Pools CRO55 ST
department. ', � + F�,IqM NqME
Pete ����n—R�DP��cant � MCI+PP F�PC}:�„�"C Qutle�S:Ret.SLight 8 sW.a � � 14 40 qDDRES
FirSt 20
CERTIFICATE OP EXEMPTION FROM WORKERS' Total Na. Additional CITY Tei No }
� COMPENSATION INSURANCE ' PLqN CHECK 0
(This section need not be completed if the work involved 4 O APPLICANT V
by the permit is for one hundred dollars(SI00)or less.) Lighting Fixtures First 20 qpDqEss . O
. Additional
Total No.�_ CITV Tsl No. F—
I�certify that tn the performance oP the work for whkh this Fixed Appliances Not Over 1 HP V
�permit is issued,I shall not employ any person in any manner PERMIT W
sn as to become subject to the Workers'Compensation Laws. Range_Heater D,W._ APPLICANT N
� O�en _Dryer_W.M._ ADDRE55 - Z
Date Applicant Top _FAU _W.H._ CITV Tal No
- Hood_Fan _Other_ •C..9 769 627-0936
NOTICE TO APPLICANT:It,after making this Certificate of Disp. _Room Air Cond__ LICENSE OR�53378 Y C-1�
F.zemption, you shoutd 6ecome subject lo the Workers' REG.NUMBE Clm
ComDensation provisions of the Labor Code,you must forth- power Apparetus&Large Appliances �ISTRICT NO. PHOCESSED BY
wilh comply with such provisions or this permit shall be $(Ze&Type HP,KW,KVA,or KVA 1 �
deemed revoked. `� �
' Up to 7 Inel. FINAL '
Ov¢t 1 to 10lncl. DATE VALIDATION �
LiCF.NSED CONTRACTORS DHCLARATION Over 10 to 50 Incl. i
I hereby affirm that 1 am licensed under provuions of ChaDter Over 50 to 100 Inc. By'0'L " �
9 (commencing with Section 7000)of Division 3 oP the Busi- � Over 100 - —'
ness and Profasions Code,and my license is in full force and .
effett. Services
License Number 153378 Lic.Class C-10 0•200 Amp.Under 600 V � '
201-1000 Amp.Undei 600 V .
Contractor e1 ectri cal Date 1�,^1Q$�. Over 1000 Amp.or Over 600 V • � � '
HOME OWNER•BUILDER D@CLARATION Temp.Power Pole&Appurtenances.. _
1 here6y afCrm-that 1 am exempt from [he Contractor's S'9^'�'ith One Branth Circuit � ' .
License Latv for the foilowing reason(Section 7031.5,Uusi- Additional Sign Branch Circuits
ness and Rntessions Code): -�0 6 2 5 A
Misc.Conduits&Conductors .
� 1,as owner ot the property,will do ehe work and the Other(See Complete Fee Schedule)— � � • • • • •2
structure is not (ntended or offered for sale (Seetion
7044.Business and Professions Code). . . �•• •2�,']�
CONSTRUCTION LENDiNC AQENCY _
I hereby aifirm that there is a construction Iending egency •�• •2 7,']�� .
for the performance ot the work for w�hich this permit is pERMIT FEE (Sub•Totall � � �
issued(Sec.3097,n�.c.).� � � � - �4 � I 1.1 6,-8:1
Lender•s Name PLAN CHECICING FEE (One•Fourth Permit Fee)
Lender's Address pERM�T ISSUING FEE � � - S SO ' �
I certify that I have read this aDV�ication and state that the TOTAL FEE ' 2,] ]Q . � �
�above information is correcL 1 agree to comply with all County , •
ordinances and State laws regulating F,lectricel wiring, and , � �
hereby authorize representetives of this County to enter upon � � �
the above-mentioned proDerty for inspection purposes. . SEE'REVERSF.FOR EXPLANATORY LANGUAGE ��
1.1-1�—$1
SiQ ure ot P ' ee • Date �
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