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HomeMy WebLinkAbout1705A WORKERS'CODIPENSATIONDECLARATION �6A663 .' APPUCATION FOR ELECTRICAL PERMIT �� � CE806G f7�80) ' � I hereby attirm �hat [ have a certiticate of consent io sett COUNTY OF LOS ANGELES � - ' BUILDINCt AND SAFETY I ' insure,or a certificate o(Workers'Compensation Insurance,or ,� ' � a certiCed copy Ihereof(Sec.3800,Lab.C.) - ��7� Company��IQ��� FORAPPLICANTTOFILLIN JpB . � � � Q .� Policy No r EACH NO. FEE ADDPESS � , � New Residential 81dgs.&Pools �Certified copy is hereby fumished: �. 1&2Famity,Sq�.Ft. S — 4 LOCALITV� � � � Certi�ed copY is filed with t ounty bu'ding inspection Multi•family Sq..Ft. CROSS ST //V '.. � Residential Swimming Paols . dep rt ent , � � P RM NAME � � Date�Applicant �'�--- Outlets:Recy�.ight Sw._ • �� � MAIL � ���st 2o nooRess S 7 E/►- B .l lJne• CERTIFICATE OF EXEMPTION FHOM WORKL•'[2S' Totai No.� Additional CITY � ei No. �y�aS��� } . , COMPENSATION INSURANCE , . ' . PLAN CHECK � a- � (This section need�not be completed if[he work IIIVOIYCA � APPLICANT 0 ' by the permit is for one hundred doilazs (5100) or leas.) Lighting Fixtures, First 20 . ADDFESS � a � Total No. Additionel � , I cenify that in the Verformance of the work for which this Fixed Appiiances Not Over t HP CITY . Tal No. U � permit is issued,I shall not empioy any person in any manner � PERMIT W . so as to become subject to the Workers'Compensalion Laws. Range_Heater D.W. APPLICANT . G- � �y ;' . � � Oven �Drye�_W.M._' ADDRESS �, s Jc� . Z Date� Applican[ Top _PAU�_W.H.._ � CITY Tel No �I � Hood_Fan _Other_ tJ/ 3 -� 7 NOTICE TO AYYLICANT:If,after making this Certifcate of DisP. _Room Air Cond� LICE SE R _ Exemption, you should 6ecome subject to the Workers' � � REG.NUMBE � J� � Cle.s � CompensaUon provisions of the Labor Code,you must forth• power Apparatus&Large Appliances DISTRICT NO.` PROCESSED eY . with comply with such provtsiOns�ar [his permit shatl be Size&Type HP,KW,KVA,or KVAP � � deemed revoked. � l0 Up to 1 Incl. ���'� � � . . - FINAL � Over 1 to t0lncl, oqrE VALIDATION LICENSED CONTRACTORS DECLARAi[ON � Over 10 to 5D Incl. - . �, I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 In4 FINAL ��i 9(commencing with Section 7000)of Division 3 of the Busi- Over 100 � BY . ness and Professions.Code,and my license is in full force and - . . � � - effect. . Services � - � - � License Numbe s� Lia Class �/ �� 0-200 Amp.Under 600 V . . � �I �p n / / 207•1000 Amp.Under 600 V Contracto�4'�T AY��4 Date /�/�[L�-1- Over 1000 Amp,or Over 600 V - � . HOME OWNER-BUILDER DECLARATION .� . Temp.Power Pole&Appurtenances � � � � �Z �17Q5A � I hereby affirm that I am exempt from the Contractor's Sign with One Brench Circuit / u License Law for the Poliowing reason (Section 7031.5, Busi- Additional Sign Branch Circuits j�/� � / �•,��•�• •2 � i ness and Professions Code): � � „�Jv � �' ��� �9,�Q Misa Conduitz&Conductors M/( - � 1, as ownet of the property,will do the work and the Other(See Complete Fee Schedule)-- � � �Y�� � ��� � � � x � structure�is not intended or offered for saie (Settion � , 9•7�� 70a4,Husiness and Professions Code). � � '.. CONSTFLUCTION LENDING AQENCY � � � O�O 2'�H Z � I hereby affirm that there is a construction lending agency ' � � � � . �. for the per(ormance of the work for �vhich ihis permi[ is pERMIT FEE (Sub-Tota�) � L '� issued(Sec.3097,Civ.C.). � , . . � � Lender's Name . PLAN CHECKING FEE (One-Fourth Permit F.ee) � Lender's Address PERMIT ISSUING FEE �� � . [cenify thaf I have read this ap0���ation and state that the TOTAL FEE � ' �'7�� � , , above information is correct.1 agree to comply with all County � . - . ordinances� nd 5tate laws tegula[ing Electrical wiring, and � ' � hereby h ize represe tatives of this County to enter upon , � , � . � � .. the ab e-n ntione pr erty for inspection purposes. � � � . SEE'[tLVERSC FOR EXPLANATORY 4ANGUAGE � ignature of�ermittee te , � ' . . .. 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