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HomeMy WebLinkAbout1597A (9) �/ WORKERS COMPENSATION DECLARATION 76A663 10/A1 APPLICATION �FOR ELECTRICAL PERMIT � � � ;l,hereby rffirm ihnt I have o cerlificarr of�onsent to self �E-8� . ins�re,or n�ert�tirate of workers'Co��pensario���sorance, COUNTY OF LOS ANGELES BUILDIMG AND SAFETY or n certified copy thereof(Sec 380Q Lob.C.) - P�ol�ity No. � Company FOR APPLICAN7 TO FlLl IN JOB - � �� Certified copy is hereby fumished. New Residentiol Bldgs.&Pools EACH NO. Fee /+oDRE55 � Certifi�ed co filed wiih ihe�cbunt buildin -�s 1&2-family,Sq.Ft. ' � _ � LOCALITY py is y g in�pec- tion deparimenf. - � � . Multi-family Sq.Ft. PJEAREST ./� / � � Residen1ia15wimminq�Pools CRo555T. L t+�` Date -Applicanl� -� /�/� - ' OWNER OR �t,/W �� FIRM NAME '�'i�T�✓� CERTIFICATE OF EXEMPTION FROM WORKERS' puHets:Rec�Light_Sw.� �MAfL � -COMPENSATION INSURANCE ADDRE55 - This seNion nead net he com leled if ihe woik Involved 6 � First 20 � P Y Toral Na� Additionol CITY TeI.No.b1��o"�(�� the permit is for ona hundred dollors(5100)or less.) . MAN CHeCK I certify ihot in ihe perfa�mance-of tFie�wark�for which.this APPLICAN7 � permit is issued,I shalt nof smploy any person in ony manner � so as in become subject to the Wnrkers'Compensation Lnws. Lighhing Fixtures First 20 ADDRESS - Addilional Totol No. CITY Tel.No. ' � Dpte '"p � Applicpn� -� Fixed Appliances Not Over 1 HP PERMIT /� NOTI E TO AP ICANT: ff, aft ''� okin -1 is Certificate of APPLICANT • . .� '[' _�g�� ��(tl Exemprion, you should bscome subjed to ihe Workers' Range�Heater_D.W.— Compensafion provisions of the Lobor Code,yoL musf forih- Oven _Dryer —W.M.— ADDRESS � � ���'„ with comply.with such provisions or this�permif shall 6e Top _FAU _—W.H:— - � �deemed revoked. � Hood —Pan _Other_ CITY .- �.� Tel.No..� . �" ��- LICENSED CONTRACTORS-0E6kARA710N LICENSE OR ���� p� I hereby affirm�hai I am licensed under provisions oi Chapfer 9 Disp. _RoOm Air Cond. — REG.NUMBER �d Clas�� (commencing with Section 70001 of Division 3 of ihe 8usiness . DISTRICT NO. PROCESS BY � Power Apparatus&Large Appliances and Professions Code,and my licens Is in full Force ond effed. '�/C G f��� �r�",7 Size&Type HP,KW,KVA,or KVAR� ��� �S` � License Number_� Lic Clas "� � Up Yo 1 Ind. fINAL . `�. ���-� � Over 1 to 10 Incl. DATE �✓ � �� yp��DATION � � Confractor �Dofe Over 10 to 50 Ind. �� � FINAL �.sy�\ ❑ I am exempt under 5ec. Over 50 fo 100 Inc. BY ��4fYd' � Over 100 � B.&P.C.for this reason , . Dale� Services,Sw6d.,MCC&Panelboprds � 0-200 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V - ❑ Over 1000 Amp.or Over 600 V Exemplion for Reg.Moint.Eleci. - - SWGLE FAMILY iemp.Power Pole&Appurtendnces - HOME OWNER-BUILDER DECLARATION Sign wiih One Branch Cirwit � . I hereby affirm thot I om ezempt from�he Contrador's License qdditional Sign Branch Circuits � `j J 4'7�' Law for the following reqson (Sedion 7037.5, Business and . Professions Code): #m e � ��'� ❑ I,crs owner of ihe property,will do ihe work and ihe Misc Conduits 8 Condudors . . struclure is not intended or affered for sale(Seclion � Other(See.Complete Fee Schedule)_ � �'��C.�U 7044,Business and Professions Code). ► " o��f1..5�1 C� a>; CONSTRUCTION LENDING AGENCY � � � I here6y affirm ihot there is n consiruction lending agency for �1 a,���%`�`�b ihe performance of ihe work for which fhis permit is issued pERMIT FEE (5ub-Total) . . � (Sec.3097,Civ.C.). ' PLAN CHECKMG FEE lender's Name . - � PERMIT ISSUING FEE Lender's Address I certify that I have read ihis opplication and sta�e thaf ihe TOTAL FEE � ` ahove information is mrred.�agree lo comply with all County � ordinances and State laws regulating Elecirical wiring,ond hereby aulhorize�epresentatives ot ihis Caunty to enter upon the above-mentioned property for inspection purposes. 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