HomeMy WebLinkAbout1616A (9) ,WORKERS'COMPENSATION DECLARAT�ON �6A� �o,a� APPUCATI�N FQR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of mruent to self CE-806G •
„�si��e,o.o ce.t�fimie ot Wo�ke�s'Compensarion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cer�lfiedr copy�hereof Sec.3800,Lab.C.) .
POol�cy Np,��.`7��'Z'��mpany S/R�r �U�� FOR APPLICANT TO FILL IN JOB /y d j
Cerfified copy is here6y furnished. New Residential Bldgs.&Pools FACH NO. fEF ADDRESS �f�'7 ��}(���/� ��L�K RCL
Q( Certified wpy is filed with the co�nty boilding insper � &2-Family,Sq.Ft. $ — $ �LOCALITY bfA��u� ���
tian department. M�Iti-family Sq.Ft. — NenRe57 o �1
/7 � y,/ n Residenfial5wimmingPools CROSS5T. p����C� r-/���
Date`�fl�$�q licont_L:11• aUD.tf�" ._�J' ?f+ OWNEROR •
PP FIRM NAME ��lCN�R� :TD/3N �/�{�
CERTIFlCATE OF EXEMPTION FROM ORKERS' OuN���_Light I Sw.� � �`'A�� (
COMPENSATION WSURANCE Firsr 20 I.4��RE55�.7Z�I �NE76HN CX�Et�' �(y
(This secfion need no+be completed if the work invofved by 7otol No. Additianal �CITY JJ�/�J'�/�d �/� Tel.No.�� ��J a Z �
Fhe permit is for one hundred dollars(5100)or less.} ( � p�qN CtiECK
I ce�iify that in the performance of the work for which this I APPUCaNi
permii is issued,I shall nor employ any person in pny mpnner j .
so as to become su6ject to the Workcrs'Compensafion Laws. Lighting Pixtures Flrst 20 � ADDRESS
� Total No. Additional
CITY Tel.No.
Date Applimnt Fixed Appliances Noi Over 1 HP PERMIT c- �
NOTICE TO APPUCANL If, ofter moking ihis Cerfificafe of APPLICANT`7(}�.Sd�1%�i (7�V � G�'N$l�
Exemption, yo� sho�ld become subject to fhe Workers' Range_Heafer_D.W. —
Compensation provisions of the Labar Code,you rnust forlh- Oven _Dryer _W.M.— AD�RE55
with com I with such rovisions or this ermii shall be � ��8� Gi.�k�MONT pG. .
FY P p Top _FAU —W.H.— � POMaivA L�Z3"Z�J�CI
deemed revoked Hood _Fan _Other_ CITY Tel.Nn.
LICENSED CONTRACTORS DECLARATION LICENSE OR }y
I hereby affirm ihat I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — P.FG.NUMBER ���p r�' ( Class. �
(commencing with$ecfion 7000)of Division 3 af ihe Business power Apparafus&large Applionces DISTRICT NO. PROCESSED BY
and Professions Code,ond my li<ense is in full force and effect. I d �
Size 8 Type HP,KW,KVA,or KVAR ( �d
License Number����z� Lic.Class � Up to' Ind. fINAI V _
S`t'JN.3C�h1G a�"� �9 v� DATE �� 1 �� p�
Coniractor f7F'�f .d P•JAfS'Tl�Date / --��`-'-' Q�er l to t01nd. , 7 VALIDATION Q
a —� � Over 10 to 50 Inci. fINAL �
I am exempt under Sec Over 50 to 100 Inc, BY �i r y�
Over 100 �lt' a,
8.8P,C.for ihis reason N
Date: Services,Sw6d.,MCC 8 Ponelboards �► � t
0-2Q0 Amp.Under 600 V �
Signature 201-1000 Amp.Under G00 V
Over 1000 Amp.or Over 600 V
� Exemption For Rey.M�inf.EIecL �
SINGLE fAMILY Temp.Pcwer Pale&Appurtenances �
HOME OWNER-BUILDER DECIARATION Sign with One Branch Circuit � i
i hereby affirm ihat i om ezempt irom the Controdor's License qdditionol Sign 8ranch Circuits �� ��,6 A �
Law for ihe following reason(Section 7031.5, Business and �
Professions CodeJ: � �
O , '{�e• e e o 2 i
I,as owner of the property,will do the work and the Misc Conduits&Conduciors
structure is no� intended or offered for sale (Section Other(See Complete Fee ScheduleJ_ � ► � •���U.5(� �
7044,6usiness ond Professions Code). a
CONSTRUCTION LENDING AGENCY m r '•�V��O u �
I hereby affirm that there is a construction lending agency for y �'���_�v
the performonce of the work for which this permit is issued PERMIT FEE (Sub-Total) aC.Q � o
(Sec.3097,Civ.C.). �
PLAN CHECKWG FEE . �
Lender's Name
PERMIT ISSUING FEE �CJ
Lender's Address
I cerrify tha�I have read this application and state�hot the T�TAL FEE �a s"� �
above intormation is correct.I agree to comply wiih all Counly
ordinances and Slate laws regul�ting Eledriml wiring, and �
hereby authorize representatives of�his Couniy to enter upon
ihe above-mentioned property for inspec�ion purposes. SEE REVERSE POR EXPLANATORY LANGUAGE
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