HomeMy WebLinkAbout0636A (4) WORKERS'COMPENSATIONDECLARATION �6A663 � APPLICATION FOR ELE�TRICAL PERMIT . ,r�
. � � CE-806G(Z�801
l hereby afPrm that 1 have a certieicate ot consent to se�t COUNTY OF LOS ANGELES BUILDING AND SAFETY U
insure,or a certificate of Workers'Compensation Insurance,or .
a tertiTed copy thercof(Sec.3800,Lab.C.) e
�SO-62494 FTeemont Indemni ty FOR APPLICANT TO FILL IN Jpg
Yolicy o. C�mDany New Residential Bldgs.&Pools EACN NO. FEE ADDPESS O],
� Cenified copy is here6y furnished. 1&2•Family,Sq.Ft. $ — § LOCALITV TRli35762 Diamond Sar .
� Multi-family Sq.Ft. — N '
Certifed copy is filed with the county building inspeclion � CROSS 5T
department. Residential Swimming Pools OWNER OR � -
FIRM NAME �ACCj.ETO Fi .SOIIB
Datell^1a'�1' wPP,;�e�tC McGee Electric Outlets:Rec.�Light�5w.�_ i� qpDRES52�OU IIllt
Fust 20
CGRTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CI7Y ��luut �.41764. Te�No.598-1821 �
COMPENSATION INSVRANCL' }
� PL�+N CHECK a
APPLICANT 0
(This section need not be completcd i(the work involved � � �2 U .
by the permi[ is Por One hundred d011ef3(5100)07 less.) Lighting Fixtures First 20 . ADDRESS
Total No.�� Additional O
I cerlify that in the performance of the work(or which this CITY Tel No. F..
ermit is iuued,1 shall not em lo an Fi%ed Appliances Not Over 1 HP
p p y y person in any manner PERMIT � W
so as to become subject to the Workers'Compensation 4ews. Range_Heater_D,W._ PPLICANT a
� � Wen _Dryer._,W.M._ . ADDRESS � N
2
Date� � ADDlicant ' ToP _FAU _W.H.._ — �
� Hood_Fan _O[he!_ CITY Tsl No
NOTICE TO APPLICANT:If,aker making this Certificate o[ Disp. _Room Air Cond�_ LICENSE OR
Exemption, you should become subject to the Workers' REG.NVMBER15337H Cla�s �-1�
Compensation prnvisions of the Labor Code,you must forth- power Apparatus&Large Applianees DISTRICT NO. PROCESSEO BY
with comply with such provisions or thta permit shall be Size&Type HP,KW,KVA,or KVA
deemed revoked. �� � p�_ �
Up to 1 Int�.
FINAL
Over 1 to101nc1, o/+TE VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.
I hereby aff'vm that f am licensed under provisions of Chapter Over 50 to 100 inc. FINAL ,
Bv
9 (commencing with Section 7000)of Division 3 of the Busi• Over 100 �
ness and Rofessions Code,and my license is in full force and � - � �
eftecL . Services � � •
�icenu lvumher 1533�H Lic.Cless C-10 OQ00 Amp.Under 600 V
201-1000 Amp.Under 600 V
Contractor Pl p�tf^i[A� ��Date '11-1QrS1 ' Over 7000 Amp.or Over 600 V .
�HOMF.OWNER-BUILDER DECLARATION� Temp.Power Pole&Appurtenances . . , . .
I hereby affirm that I am exempt from the ContractoPs Sign with One Brench Circuit .�
License T.aw fm the following r-ason(Section 703L5,Busi- Additional Sign Btanch Circuits _ . �
ncss and Professinns Code): � � .
n�tise.Conduits&Conductors� z 0 6�6 A
� 1,as owner of the property,will do the work and the Other(See Complete Fee$chedule)—
strutture is not intended or offered for sale (Sec�ion . r�o���• •;��`�
7044,Business and Professions Code). � �
CONSTRUCTION LHNDWG AOENCY � • • � $,� � "
1 hereby affirm that there is a constructfon Iending agency -
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) •.�.' � 8� C/c� �
issued(Sec.3097,Civ.CJ. �
Lender's Name � PLAN CHECKING FEE (One-Fourth Permit Fee) I L�,6—B��
Lender's Address PERMIT ISSU�NG FEE . �8� a
I eet�ify that I have read this applicalion and state ihat the TOTAL FEE
ahove informetion is correcL I agree ro comply with all Connty . . ,
ordlnances and 5tatc laws tegulatin¢ F.lectrical widng, and � '
hereby outhorise representatives of this County fo enter upnn
the above� entioned roperty for inapection purposes. SEF.'REVERSE FOR LXPLANATORY LANGUAGE -
�.1-1�-81 ' " _ .
Signet of Permi Date-
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