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HomeMy WebLinkAbout1148A (5) 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 ✓ � � � � � t✓' ����.5 � � ; Signoture of�..rmiltee Date - - � �� 7 � , c � � �° "°3 Q o . � -n � p � P3� G �.,, � � 'v 7y' � - O � � � � � � w �� Q � �� � G � „�'�^ � � � G C7 -s7 � � ...q 'Sry � rJ � -1 X � cn ' � �' F m O �. ' � t � 1 - � � ,� f �.'; . O �j ' °• ;�', � ! 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