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HomeMy WebLinkAbout1343A (7) � . ! _ �WORKERS'COMPENSATIONDECLARATION 76A663 10/87 A�PLIC�TI�IV F�R ELECTRICO�L PERMIT � i ct-xosc; I�hereoy affirm that I have a r.ertlficate of consent to sclt insure, or a cPrtificate t;Workers Cnmpensation�nsurance,or a certified COUNTY OF LOS ANGELES BUI�DING AND SAFETY � copy thereof(Sec:�3800,tLabC,� � y �1 - � Polic �t���t1t)��r.�11' LI L�.t-G�:tiv��t.�L=,c--� Y+ .,ompan� FOR APPLICANT TO FILL IN JOB �� ❑ Certitied co is hereb furnished. EACH N0. FEE ADORess . � w.� �� . . PY . Y . ,. Neai Residential Bldgs.&Pool y - t&2 amil S Ft �_.�� $ — $ LOCALtTY� r- � '�Certifietl copy is filed with the county building inspection Y, a� NEaR�si de rtmesk. i ��v- �),,,_}-, Mul�a Ft. � Cftpss 5T. . Date ���r� Applican��/�"'"j" J rs 7��-'`-�-,�-r-,. �eside ia�l Sw�lmrniny Pools owNER�R nRnn Nn,UE � . .v � CERTIFIGATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light_Sw.—. Mai� � w`�� � - � � COMPENSATION INSUHntvcE nooaess �� �(This�section neetl not be compieted'rf the work invo4vetl by the First 20 � - permit is for one�hundretl dollars($100)or lesaj - Total No. Ad<iitional ��T� C_ TeL tl��.��_' � 1 certify that in the pPrformance of the work for which this permit PLAN CHECK is issued,I shali not employ any person in any manner so as to APP��I�t�Ni become subject to the Workers'-Compensation Laws. Lghting Fixtures First 20 ADDRESS Additional Total No. GTY lel.No. Date Applicant Fixed Appliances Not Over 1 HP --�------ NOTICE TO APPLICANT: If, aker making this Certificate of PERMIT 1 1�^� Exemption,you should become subject to the Workers'Compens�tion Range_ Heater_ D.W. _ APPUCaNT �, � ��.(���..L a`J provisions of the Labor Code,you must forthwith compfy�with such Oven— Dryer_ W.M._ AQDRESSe � �. � ���� . provisions or this permit shall be deemed revoked. . . T _ FAU _ W.H._ � • � LICENSED CONTRACTORS�ECLARATION � CITY .� ��,�y��, Tel.N �'-�-p'/� � Hood— Fan _ Qther_ d� �,.�-�J . �I hereby affirm that I am licensed under proYisions of Chapter 9 . Disp. — ftoom Air Cond _ uCENSE�R �� [�-; aass l`- i � � (commencir�wtth Section 7000)of Division 3 of the Business and AEG.NUMBER �l� /. � /'�� Professions Gode,and my license is in full force en�effect. DISTRICT'JO. PROC,E:SEfl.[lY r Power Apparatus 8 Large AppGances f ��"� �y � Size&Type HP,KW,KVA,or KVAR ����_ p , license Numberc�� !� � Lic.qass -- j�� � Up to 1 incl. � FINAI �"� - ` V ' (� � �!/.e,��u{._ �����3 Over i to 10 Incl. DATE � � � ��� VALIOATION � � CoNractor -�^4-� � � �Date � O�er 10 Io 50 Incl. Q I am exempt under Sec Over 50 to 100 Inc. i FINAL �9 V BY W �. B.&P.C.for this rea5on _ Over 100 � - . . -- � Service;,Sw6d.,MCC 8 Panel6oarcJs , � - � Z Date: 0-200 Amp.Under 600 V . Signature � 201- 1000 Amp.Untler 600 V � , � ❑ � � � � � Over 1000 Amp.or Over 600 V Exemption�for Reg.Maint Eiect � SINGLE FAMILY Temp.Power Pole&Appurtenances ; HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � I hereby aftirm that I am exempt from the Contractor's License Law for the foilowing reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits .. . . Code): Misc.Conduits&Conductors ( ❑ I,as owner of the property,will do the work and the structwe � �� 3 a,��, � is rrot intendetl or offered for sale(Section 7044,Business Other(See ComPlete Fee Schedule)_ . � and Professions Code). . , � e m s e m� iGONSTRUCTION LENDING AGENCY � i � ,i �,� ,7 R I hereby affirm that there is a construction lendirig agency for the f performance of the work for which this permit is issued(Sec.3097, pERMff FEE (Sub-Totap x i Civ.C.l. � � � ��•��=-: . � PLpN CHECKING FEE Q�,�j-�j 7 � Lender's Name � - PERMIT ISSUWG FEE �, Lender's Address �� � � I certify that I have read this application and state that the a6ove - TOTAL FEE information is correcf.I agree to comply with rll Couniy ordinances � and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned operty for inspe.Ction purposes. j / /� SEE REVERSE FOR EXPLANATORY LANGl1AGE �, 7 X-�_�..r-r� _.:1..�'� �_-� , �,��.�� _: J ., Sipnature of Parmitlee Date I �°`f�5 '� • O G"-7 C "''�" C .fi }-• :>. 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