HomeMy WebLinkAbout1148A p �NORKERS'COMPENSATION DECLARATION 75A�3 10/Sl �q�p�'�q�iON FOR ELECTRICAL PERMIT
I horahv nffirm thai ! hove c rertitimte nf r ent tn�elf �`-806G
insure.or,a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY l �
or a certifi=d mpy ihereef(Sec.3800,Lab.C.� „�� ' {f j� ��� >
� ��P''o��l;;icy No. Com�any � FOR RPPtICARIT 70 FlLL IN ��g .^ry�J J� ` t dr < � � .
� Certified<o is hereb fumished �q�� i��p_ .: ADDRESS z�4 7'f F f�� .
� PY Y New Residential Bldgs.&Pools `
1&2-famil 5 .Ft__ � — S LOCALITY h
� � Cerfified copy is illed with ihe munty building inspeo- Y- 9 � _ �
tion depariment. Multi-family Sq.R.�''� ,�I"� �NeAeeST
� ''� Residential Swimming P{�ols OWNER OR / �
� Dafe ���'-�Applican} °7f.y�,�gy g.,./Z Gg„��„"�',� fIRMNAME '�6'j.L� �'C� �d°�J -
� CERTIPICATE Of EXEMPTiON FRCM WORKERS' OutlelsYRec Light___Sw.�' I �NJiIL + �
� COMPENSATION INSURANCE •Cj;�'� A�oRF45
First 20
� (Thia setfion need not be rompleTed iF ihe work involved by 7atal No.� CITY �,b� �y`'� Tel.No.�( . �,tj �— �
�' the permi4 is for one hundred dollars(5100)or less.) Additional i ���
FLAN CHECK �
5 I certiEy that in the oerformance of the work for which this I AP7LICF�N7 �
� perriiil is issued,I shol!na'eroploy any person in any mpnner „_„_
so as to become subject to ihe Workers`Compensation Laws. �� Llghting Fixtures First 20 I AODRESS �
' ' Additional �
g � To!al No. � CITY �' Tel.No.
Date Applicant - fixed Apphances Not Ovet I HP � � +PERMIT �� �} {—
� NOTiCE TG APPLICANT: If, afier rt�akiny ih s Certiticate of I I APPtICANT ....(��L!6��'j_,l. ���' h �
� Exemption, you should become subject to tne WorRers' Range_Heoter_.0.W. �
Compensation provisions of ihe Labor Code,you m�st furth- Oven _Dryer —W.M.— � �ADDRESS � �7� �'�y� ���a� �
� with mmply with such pro��sions or Ihls permit shall be Top _FAU —W.H.— ( ' - ' :
deemed revoked. . C7TY �' Tel.No,�r ;�� �q�„�a-,
� - � �� � � � �- � Hood _Fan _Other_
� LICENSED CONTP.ACTORS DECLARATIQN � � LICENSE OR
I hereby affirm thot I om licensed under provisions of Chapter 9 Diso. Ruom Ai�Cond — � RE6.NUM6ER �'J';�<:.3 Gk � � Class. (�. ��
� (mmrnenting v✓ith SeCion 7000}cf Division 3 of the Business I � DiSTRICT NO. PROCESSED BY
� and Professions Code,and my license is in fvll force and e�fect Power Apparotus&Larae Appl�ances I I � � /� �
� �f / Size&?ype NP.KW,KVA,or�CVAR I � O �
� License Number 'r"-3 a Lic.Clats �' �' � � � FINAL �- � �
� . -. _ Up to 1 Ind. I � F' DATE =w �=..,' �
f� /�p� ��h/ / Over 1 to 10 Ind. VALlDRTION �
Conimcfor ✓•�� ` � 'd Date � - �
� � F ✓ S �.`"� "�'� 6�er 10 to 50 Ind. � "FINAL � �
� I am exempt under Sec Over 50 to 1 W Inc. � 9Y �\ - �
� � Cver 1p0 � R � �"`�-�'� - � �
B.&P.C.for this reason i'— --� ' - � ._
i
Date� Services,Swbd.,AhCC&Panelboards � ��
� - � � 0-200 kmp.Ur�der b00 V �
�i Siqnature � 207 -lOW Amp_Under 600 V �� �I
--___—
� � Over 1000 Amp.o;Gver bOG V � � _ -
Exemption for Reg.Maini.Elecf. �
� i ��.�S l�:
� SINGLE fAMILY �Temp.Power PQte&P,ppurlQ�n�:es -� � � �
' HOMr OWNER-BUILDER DECLARATION Sign with Or.e 8ranch Circ�it � � T�` � $ '��-
�� I hereby affirm thnt I om exemptfrom fhe CoMroctor s Llcense Rdditionq)Si Bronch Circvits �� ' 7
� Law for ihe following reason �Sedion 7031.5, 9osiness and g" f �� �.�
J Professions Code): � , . -,- ,�
� Misc.Conduits&Conductors � .° `> ..� ;��-�,- .:
I,as owner of the property,will do rhe work and the
� sirudure is not intended or otfered for sale (Sedion Orher(See Comple'e fee Schedule)_ �.� �,?C�` � S�t� �
i 7044,Business and Professions Codel. 4 . � '`
q CONSTRUCTION LENDING AGENCY ��`---- -- - - ��
- I hereby afflrm ihat ihere is a consfrucfion!ending agency for , �'�
� ihe performance of ihe work for wnich�'rus perrn�i is issued �. pERMIT FEE (Suo-Totaij ��-
(Sec 3097,Civ.C.). � �
� PLAN CHECKING FEE . `
� Lender's Name - �
. PERMIT ISSUING FEE �D .
Lender's Address .
I certify that�hove read this application and statc fhaf ihe - TOTAL FEE � - �� ,
; ebovc irformatior is correct.!agree fo com.ply wi?h o!!County . '
ordinnnces and Sfate Iam�s regolpiing Electriml wiring, and - .
here6y authorize representNives of this County to enter upon - '
! the a ov -mention d properry for inspection purposes SEE REVERSE FOR EXPIANATQRY LANGUAGE
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