HomeMy WebLinkAbout0635A (4) WORKERS'COMPENSATfON DECLARATION 76A663 ppp���ATION�FOR ELECTRICAL PERMIT � �
CE�SO6G(2-80)
1 hereby attirm that I have a certificate of consent to ae�t COUN7Y OF LOS ANGELES BUILDiNG AND SAFETY
insure,or a cerNficate ol Workers'Cnmpensation Insurance,or � Cd�, OT�� �3 . '
a certi�ed c�py thereof(Sec.3800,Lab.C.) T
vo�i�yWi�o80-62494comvanFreemnt Andemn�t'Y FOR APPLICANTTO FILL IN qDDRE55 40.1 Gold:en S T 9 DT.
� New Residential Bldgs.&Pools EACH No. FEE p �
� Certired rnpy is here6y furnished. 1&2•Fami�y,Sq.Ft. $ — $ LOCALiTv Z
Q Certified copy is filed with the county building inspection Multi-family Sq.Ft. CROSS ST
depanment. � Residential Swimming Pools OWNER OR
FIRM NAME
Date ��^�n^��Applicant C McGee El ectri c Outlets:Rec._Light 4 Sw,_ MAl l
� 'First 20 ADDRESS �Onl Walnut Dx.
CERTIFICATE Or EXEMPTION FROM WORKERS' Total No. Additional - CI7V Ta1 No. 2 }
COMP£NSATION INSUNANCE � FLAN CHECK a �
(This aection nred not be completed if the work tnvOWEd P.PPLICANT O
by the pe�mit is for one hundred dollara (f100)or less.) Lighting Fixtures First 20 , qooReSs
Additional �
Total No.�_ CITY TN No, �
1 cer[ify that in the performance oP the work for which this� Fixed Applianees Not Over 1 HP F"
permit is issued,I shall not employ any person in any manner pERMIT W
so as to become subject to the�Yorkers'Compensation,Laws. Range_Heater._D.W.^ ApvLiCANT ��� a
Oven ..._Dryer_W.M,_ ADDREsS p,O. BOX ZH Z
Date qpplicant Top _FAU _W.H,_ —
Hood_Fan _Other_ CITV Tel No ,
NOTICE TO APPGICANT:If,after making this Certiflcate of Disp. _Room Air Cond,_ LICEN Crlo
Ezemption, you shouid become subject to the Workers' REG.NUMBERZ�J337H Clns
Compensation provisions of the Labor Code,you must forth- power Apparatus&Larpe Appliances DISTRICT NO: PROCESS(E�D eY
with comply with such provisioni or this permit shall be Size&Type HP,KW,KVA,or KVA , � O �
deemed revoked.
UP to 1 Intl.
FINAL
LICENSED WNTRACTOR5 DECLARATION Over 7 to 101ne1. - DATE / VALIDATION ' �
Over 10 to 50 Incl. 1
1 hereby affirm ihat I am licensed under provisions of Chapter Over 50 io 100 Inc. FINAL
BY
9 (tommen[ing with Section 7000)nf Division 3 of the Busi- p���pp
nesa and Prnfesaions Code,and my license is in full force and
effect. Services
License Number 153378 Lia Class C=10� � 0-200 Amp.Under 600 V � �
11�1Q 9�, 201-1000�Amp.Under 600 V
Contractor el ectri cal pate Over 1000 Amp,or Over 600 V
HOMG OWNER-BUfI.�ER DECLARATION Temp.Power Pole&APpurtenanees '
I hereby affirm that 1 am exempt from the Contractor's Si9n with One Braoch Circuit .
�ecHon 7031.5,Busi• Additional Sign Braneh Cireuits
License Law for the follnwing reason(_
ness and Profesxions Code): .
Misc.Conduits&Conductors . �
� i,as owner of ihe property,will do the work and the Other(See Complete Fee Sehedulel— '
structure is not intended or offered for sale (Section-
'7044,Business and Professions Code). �
� CONSTRUCT[ON LFNDiNC AOF.NCY - �O b�S A
I hereby a(firm Ihat there is a construction lending agency .
for the performance 6f fhe w•ork Por which this permit is �� �-�-���2
issued(Sec.3097,Civ.C.). � . PERMIT FEE (Sub•Total) �(+1 Q .
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel � ��i ' '� �`3�
Lender's Address � ° � � �3�U
PERMIT ISSUING FEE . '8. Q. �
1 ttrtity that I have read this appliaation and state that the TOTAL FEE 3 O � �'� 6—a.� . �
above informallon is corrcct.I agtee to comply with all Cannty . .
. ardinances and State laws regulating Electticai wiring, and �
hereby aWhodze representati��es nf this County to enter upon � � .�
the above�mentioned property for inspection purposes.� SEE'REVERSE FOR EXPLANATORY LANGUAGL
, 11-1�—$�. . ' .
Sign re of P �ittee Date . ' -
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