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HomeMy WebLinkAbout1277A WORKERS'COMPENSATION DECLARATION ' ���� ���81 APPLICATION FOR ELECTRICAL PERMIT � � f hereby offirm that I have a ce��ificate of consent to self CF�BOOG �nsure,or a cerrificaie of Workers'Compenso�ion Ins�rance, COUNTY OF LOS ANGELES BUILDING AND SAFETY �or j� F.d��•�p p�L�th�ereof(Sec.3800,Lab.C.) 1f��'���Company �'"� fORAPPIiCANTTOflILIN JOB Certified copy�s hereby furni ed. New Residenfiol Bldgs.&P EAC NO. FEE AD�RE55 � 1$�-Fom�l 5 Fr. 5 — S IOCAUTY � Ceni(ied mpy is(iled wilh the counly building inspec- Y• 9• _ ��� dep rtment. ,,,,,,���///+++ Mulii-fomily Sq.FI. CROSSSST. 'r � �/?M///��� Residentiol Swimming Pools OwNER Ok Dale Appliconl fL , FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Ligh�_Sw._ - ��� �` COMPENSATION INSURANCE� ADDRE55 � Firsl 20 (This s�clion n��d not b�cempl�t�d iF 1h�work�nvolv�d by Total No. Addilional � CITY �/� Tel.No � th�permil is For on�hundr�d dollars(SI00)or Ivss.) I certify ihot in the perfwmance of the work for which Ihis . PIAN CHECK APPLICANT permit is issued,I shall not employ any person in any monner so as�o become subjecf fo�ha Workers'Compensation Laws. lighting Fixtures Firsl 20 ADDRESS - � Tmal No. Addiiionol CITY Tel.No. � opplicant Fixed Applionces Not Over 1 HP pERMIT / �/ NOTICE TO APPLICANT: If, o{�er making Ihis Certificate of Ran e_Heater_D.W._ APPLICANi ` � � Exemprion,�yoo sho�id become subjeu to �he Workers' 9 Compensation provisions of the Labor Code,you must forih- ' Oven _Dryer _W.M._ A�DRE55 �� / ith comply w'th such provisions or thia permii sholl ba .Top _FAU —W.H.— deemed revoked. ' �� Hood _Fan _Other_ qtt.', �{/� Tel.No. IICENSED CONTRACTORS DECLARATION tICENSEOR p�2 Class�% �isp. _Room Air Cond. — REG.NUMBER U �hereby offirm ihot I am licensed under provisions of Chopter 9 a. (tommencing with Secfion 7000)of Division 3 of Ihe Business power Apparotus 8 large Appliances DISTRICT NO. PROCESSED BY O and Professions Coda,and my licensa is in full forca and eHect. �v U �,n Sixe B Type HP,KW,KVA,or KVAR� License Number � Lic.Closs� U to 1 Ind. . FINAL � �+) P DATE /iZ/�/��!� � /�/p��p /�p/ Over 1 to 101nc1. YAIIDATION- V ConrraUo[i/c�C-1/��`�[L��Date.�,�� Over 10�o SO lnd. FINAL � � � ❑, I am exempt under Sec. Over 50 to 100 inc BY N B.BP.C.for this reason Over 100 Z � � � Da�e: � � Services,Swbd.,MCG 8 Panalboords ► � 0-200 Amp.Under 600 V Signolure 201-1000 Amp.Under 600 V _ � Over 1000 Amp.or Over 600 V - Exemption for Reg.Main�.Elect. j SINGIE FAMIIY ' Temp.Power Pole 8 Appurtenances +�?� 2']�']A � �•� HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ' I hereby affirm ihoi I am e.empt from the Contmctor's License � o � � � Law for the following reason(Sec�ion 7031.5,Business and Additianal Sign Bronch Circuits � •2 , Professions Code): ' I + •b 3,0 6 � , M:sc.Conduits 8 Conductors . I,as owner of the property,will do the work and�he Q�her(See Compleie Fee Schedole)_ - • o •6 3.0 6 structure is noi intended or ofiered for sale(Section . u 7044,Buziness and Professions Code).'� � CONSTRUCTION LENDING AGENCY 0&2 5—8 6 . I hereby offirm thoi�here is a consiruction lending agency for � the performance of the work for which Ihis permit is issued PERMIT FEE (Sub-Tolal) � (Sec.3097,Civ.G.). � � � PLAN CHECKING FEE - - ' � � Lender's Name PERMIT ISSUING FEE � � Lender's Address ' ' 1 certify tha�I have reod this oppiicotion ond state ihot the TOTAL FEE 3� above information is correct.I ogrea to comply with oIl Counly _ ordinances and Stote lows reguloting Elecirical wiring,and . . � � � � � hereby outhorize represenrotives of ihis County ro enter upon � � the a ve•menrioned prope�ty for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE ����� 8��� � SignaWre of Permilfee �. Dole ;� '. , .-.;.,- r,� , .. 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