HomeMy WebLinkAbout1381A WORK�Hs'C05(PENSATION�ECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT � �
CE-806G(2�801 . ;
1 hereby sffirm that I huve a certificate of consent tn selt COUNTY OF LOS QNGELE�fr' S BUIL�ING ANp SAFETY
insure,or a certificate ol Workers'Compensation Insurance,or �' • �,/� � // -
a certified copy Ihereof(Sec.3800,Lab.CJ � " ��/ iC/�<<G-✓ !'� �!G �7
�L��S'�% �' � FOR APPLICANT TO FILL IN � �OB ("� •L `.�1p�(�Gf� S -ITI '
PoliCy No. Company ���j"� NeW Residential Bldgs.&Poo15 EACH NO. FEE ADDRESS JvXSC..r
� � Certitie�copy is he�eby tutnished. . 1&2-Family,Sq,Ft. S — � LOCALITV � � ��d � �
Muiti•family Sq.Ft. NEARE57
�CertiCed copy is tiled<v�'� qnty building inspenion U • CROSS ST �
department. ' 1 � �Res!idential Swimming Pools OWNER OR r �,/
` � //.rr.f � ,�2�'' �-' FIRMNAME /�2'L. J/��'�N ��+D
Dat '�Apylica� Outl��Rec._Light_Sw._ MAIL '
FirSt 20 P.DDRESS
CERTIFICATE F EXLM1IP ION FROM WORKERS' � Total No. Additional CITv Tei No.
� COSIPENSATI INSURANCE }
PLAN CHECK • `�/S a
APPLICANT Qf1�/.� .s1I ( �L.
fThis section need not be completed if the work involved O
by the petmit is for one Fundred dollazs(5100)or Icss.) Lighting Fixtures ,First 20 ADDRESS �� V
Total No. Additional �
� certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CI7Y Tel No. O
tpermit is issued,I shall not employ any person in any manner PERMIT V
�so as tn become subject to the Workers'Compensat�on Ln��•s. Range_Heater_D.W._ - qpp�icqNT ty �+ ( r;►O�( [� W
d
Oven _Dryer_W.M._ ADDRE55 '3 � Ef � y
Dete App�icant Top _FAU _W.H._ ` Z
Hood_Fan _Other_ � CITV j�,� � �,�+��/� Tel No.4,lr�C,s`3 6
NOTICE TO APPLICANT:If,after making this Certificate of Disp. _Room Air Cond�- LICENSE OR Z
lxemption, you should 6ecome suhject to the Workers' . REG.NUMBEH j��°G �� Class �.S` 7 �
Compensation provisions ot the Labor Code,you rtlUSt f�fth- pOWBf Apparatu5&Large ApplianCes � DISTRICT NO. PROCESS€D BV
,��ith cOtnply «�th Snch provisinns or [his permit shall be
'deemed revoked. Size&Type HP,KW,KVA,or KVA /O �`(�1��,
1� Up ta 1 Intl.
f Over 1 to 101nc1. FINAL �
DATE
( LICENSF.0 CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl.
hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc. FinlnL
(commencing with Section 7000)o(Division 3 of the Busi• � B�
Over 100
ss and Nrofessions Code,and my license is in fuli force and
�fect. 7 ' $ervices . �
' License mbe� � � L/ Lic.Class C'S^� ' OQ00 Amp.Under 600 V � �
r� 207•1000 Amp.Under 600 V
Co ra ��ate �'��—r r Over 1000 Amp.or Over 600 V ' �
�HOMG OwNER•BUILDER UECLARATION Temp.Power Pole&Appurtena�ces �
I hereby affirm that I am ezempt fmm the Contrector's Sign with One Brench Circuit ,
I,icence Law for the following re±son(gection 703t.5,Husi- Additional Sign Branch'Circuits � `� 3 H,� A
ness and Professions Code): �� � � � �� �
Mism Conduits&Conduttors
� 1, as o�vner of the praperty,will dn the�vork and Ihe Other(See Complete Fee Schedule)— �,• �5 Ei 5 0
structure is not Intended or otfered for sale (Section
�7044,Rusiness and Professions Code). ° • •5 A 5 0 u
CONSTRUCTION LIiNDING AQt]NCY
1 hereby af(irm ihat there is a consiruction lending agmcy ��.2(��b+2
for the �performance of the work for which ihis permit is - '
issued(Sec.3091,Civ.C.). - PERMIT FEE ISub-Total) ��
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Fee) �
Lender's Address pERMIT ISSUING FEE 5 ,
1 certify that 1 have read this application and state that the TOTAL FEE J� �
above information is correct.i agree to romply with all County . , .
ord' and State laHs reguiating Eiectrical widng, and �
, ereby au n( representatires of this County to enter upon
�the abo�-m t'roned prop for inspection purposes. SEE'RCVERSE POR F•.XPLANATORY LANGUAGE
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