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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. SEE REVERSE FOR EXPLANATORY iANGUAGE
Sign�Per tr�e — � Dafe �� _____ __ ___ _ _---
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