HomeMy WebLinkAbout1149A � - WORKfRS'COMPENSATION DECLARATION 76A663 i0:et �ppL��qTl4N FOR ELE�TRICAL PERMIT i1 .
I hereby�affirm ihat I hove a certificate of conseN to selt CE-806G
§ ms�re,or.a certificare oi Workers'Compensaiion Insurance, Ct'U�ITV OF LOS ANGEIES .r/ �,z� �URDiNG AND SAFETY ��� �S� �
1 cr�o.certified mpy fhereof(Sec.3800,Lab.L.�) o�-y
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( Poliry No. Company FOR APPUCART TO FILI IN � B �y �/ f �,
� n i [AiH NU. ctE _;��DP.cSS "h 5`�,;�� �o L� � C% � i
� � Cer;ified copy is hereby furnished. New Residential Bldgs.&Pools
� � Certified copy is filed with�the county bvilding inspeo 1 &2-Family,Sq.Ft— 7�—��L� _ $ LOC,ALITY �
,,., i,ion deparimeni. , . Multi-family Sq.R. �va � -NEAREST
i � - � CROSS ST. .
I "7 _9 C3,qPP�can Residential Swimmin Pools pbyNeR OR � � �
d Date_�A � �=G��,�,g� �
wy� � �FIRM NAME /
�� CERTIFICATE OF EXEPA,P?�ON PROM WORKERS' � � ! ' '�"-' � ��MAIC yj�
- Outlets:Rec_tight`Sw.__ 1 � •
� COMPENSAi�pN INSURANCE � ��/ Firs120 - '� g� p��RF55 �- . �,
� (This section need noP be mmpleted if tbe work invalvad by Tot�l No.�_ qddiiional i CITY �(} ��y�u Tel.No. j, _ � �
y 4he permi4 is fo�one hundred dollurs(5104)or less.) ' .
� I certif thot in the erformonce of the work for which this PL4N CHFCK C3j �
� y P � I APPLICFNT `� /
� permit is issued,i shall not employ ony person in ony manner �
� so-as to became subject to ihe Workers'ComQensation Laws. Lighting Fixtures First 20 AGDRESS__
- - - � Total Na Additionaf -.—. CITY Tel.No.
Date Applicant - �- ���- fixed Applianws Not Over 1 HP pERMIT `� - -
NOfICE TO AFPLICANT: if,-after making this Certificate of qpPu�qNT /4..Q j� ,. � "'' u� �' �
�_ Exemot�on, you sheuld become su6jec« !c the Workars' Range�Heater_D.N,i. — � � -
-� Compensahon provisions of the labcr Code,you must forih- Oven _Dryer ,—VJ.M— �.4DDRESS ''7 �' Ai.ta�S v .�- �
with ,omply wirh such provisier s or this permit sholl be lop —FAU —W.H.— -
� deemed revoked. �CITY �� �� ����S Tel.No.� 7 � �� � .
Hood —Fan _Other_ ,�
LICENSED CONTRACTORS DEC'IARATION i LICENSc OR
I hereb�affirm thnt I am I'censed� ide p ovisior�s of Chapter 9 Q�sP' —R°om Air Co d. — �REG.NUMBER J��•� �c`� Class. � '�
� (commenc�ng wlth Sect�o 7ppOJ of D�v sion 3 of the Business � �7STRICT NO_ � PROCESSED BY �
� nnd Profess.ons Cod aad .:�!i �e is�n full foree ard effed. Power Annorntus&La ac Anpliances � � �
Size 8 Type HP,KW,KYA,or KVAR (�
titense Number.-�Lic.i;lass_.�� . Up to 7 Ind � �FINAL °oJ�
� I r �✓Y� s Over 7 to 10 Ind. DATE j ;p,.-��, g_.,.� VAIIDATION �
Conirac!or���ZP7 ���+��-S" �ate '�'y���•�+ Over 10 fo 50 Incl. � �-
r- FINAL q�
❑ I am ezemp`under Secl..... Over 50 to 100 Inc. BY �„�..--��, ._����,,,..- � �,
� B.&P.C.for rhis reason — Q°ef�� �� �- I �
Se ices,Swbd MCC&Panelboards � �°� ;
S Uate: 0-200 Pmp.Under 500 V — �
� Signature 207 -1000 A ip.Under 600 V �, '
� ❑ Over IOQd Amp.or Over 50p V �
Exempiion for Rsg.Maint E;ect. � �
SINGIE fAMILY emp ower Pole�Fappur�enonces
HOME OWNER-BUIIDER DECIARATION �Siyn wi�h One Branth Circuit � �i I !`.!N
I hereby affirm'ha�I am exempt from ihe Conirr�c?or's License -qdditional S'gn$ronch Grcuits .y:
Law for the following reason(Secti�n 703L5, Business and . ;q a � r�. e =<'�
Professions Code�: �
❑ �,as ov,�ner cf th2 prop�r�y,will do the w�ork�nd the �Misc Conduifs&Goridociors ( � �.c;�,: _
strvcture is not in!enden or offered for sale (Section Other{See Compiete Fea Schedole)._ � � �-z v .� -�`
7044,Business and Professions Code). -_...
CONSTRUCTtON LfNDING AGENCY . � G�V.:i"�7-
I hereby a`firm thai ihere is a construction lending agency for � .
the perfurmence of ihe work for which this permH is issued � pERMii PLE (Sub-Total) ,��3 5� . .
� (Sec.3097,Civ.C.�.
PLAN CHECKING PEE
Lender's Name
PERMIT ISSUING FEE fd ��� .
�� Lender's Address .
� I certi'ty that I hove read this applimtion and sfafe ihat the TOTAL FEE �,7 � � .,_
ahove informafion is corrett.I agree to comply with all County
�- ordinances and Sta�e lows reguloting Elecfriml wiring, cnd �
hereby�uthorire representatives of this County io enter upon
� th ove-men��oned prop rt for inspedion purposes. � '
9 SEE REVERSE FOR EXPLANATORY LANGUAGE
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