HomeMy WebLinkAboutNo Permit Number (108)WORKERS'COMPENSATIONDECLARATION
ness an ro eastous Lod
76A663CE so., APPLICATION
FOR ELECTRICAL PERMIT
Li
I hereby affirm that I have a certificate of consent to self
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Policy P80 --6z 9.1pa 'YemOYlt IYICIP_IIlI11'L�7'..
FOR APPLICANT TO FILL IN
OB
"'
New Residential Bldgs. & Pools EACH NO.
FEE ADDRESS _ A2— 20631 2
DY,
Certified copy is hereby furnished.
1 & 2-Family,Sq. Ft. 25512 $ "'
$ - LOCALITY M! 33645—A Rowland Fief )1
Certified copy i5 filed with the county building inspection
Multi-famiFt.y Sq
l . —
NEARES T
CROSS ST
-
department.
Residential Swimming Pools
Presley Co.
ORM
Date 4 1,-.81 Applican1(7'1 mr'-(_PP F.1 P0J_ 'i 0
Outlets: Rec3 Light 1 Sw. -
NAM
FIRM NAME
2. 4 MAIL .r PU
-
-
First 20
ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS'
Total No. Additional
CITY Beaeb Tel No. _ 0500
>
COMPENSATION INSURANCE
Plata CHICK
(This section need not be completed if the work involved '.
APPLICANT
by the permit is for one hundred dollars ($100) or less.)
Lighting Fixtures First 20
g g
64- ADDRESS
cc
Additional
Total No. I
O
i certify that in the performance of the work for which thisFixed
Appliances Not Over i HP
CITY Tel No.
permit is issued, I shall not employ any person in any manner
PERMIT -
LU
so as to become subject to the Workers' Compensation Laws.
Range.__ Heater_ D.W. _
APPLICANT n u
C�.,
-
Oven _ Dryer _ W.M. _
ADDRESS•
P.O. Box -2886
i'
Date Applicant
Top _ FAU _ W.H.._
Hood — Fan _Other_
CITYPomona Tel No. Z
_
NOTICE TO APPLICANT: If, after making this Certificate of
Disp.. Air Cond.
LICENSE OR C,-10
153378
Exemption, you should become subject to the Workers'
_Room _
REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- `
Power Apparatus & Large Appliances
DISTRICT NO.
PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked.
Size & Type HP, KW, KVA, or KVAR
>
n>f
Up to 1 Incl
LIC ENSI?L1 CONTRACTORS DECLARATION
Over 1 to 10 Incl.
FINAL
DATE
VALIDATION u
Over 10 to 50 Incl,
I hereby affirm that I am licensed under provisions of Chapter
Over 50 to 100 Inc.
FINAL
BY
9 (commencing with Section 7000) of Division 3 of the Busi-Over
100 -
ness and Professions -Code. and my license is in full force and
erfect.
Services
153378 C-10
-0-200 Amp. Under 600 V
<- (: �- 7. A 1
License Number Li, Class
201-1000 Amp. Under 600 V
Contractor Electric 1Date 4-1-81 _
Over 1000 Amp. or Over 600 V
C>
HOME OWNER -BUILDER DECLARATIONS;
Temp. Power Pole &Appurtenances
-
[ hereby affirm that I am exempt from the Contractor's
Sign with One Branch Circuit
n' "* �" �' t?
CAdditional
License Law for the following reason (Section 7031.5, Busi-
dP P
Sign Branch Circuits
r. 4 - R
v fi
e). -
Misc. Conduits & Conductors - -
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)-
- structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructionlending agency
for the performance of the work for which this permit is PERMIT FEE (Sub -Total) 78. 39 -
issued (Sec. 3097, Civ. C.). -
Lender's Name ---- PLAN CHECKING FEE (One -Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE - - -
I certify that I have read this application and state that the TOTAL FEE 36. eg
above information is correct. I agree to comply with all County - -
ordinances and State laws regulating Electrical wiring, and -
hereby authorize representatives of this County to enter upon '
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE: -
/
4-181
Sigtr' ure of PerrI Date
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