HomeMy WebLinkAbout1400A -WORKERS'COMPENSATIONDECLARATION 760.663 �0,8, . qppLICATION FOR ELECTRICAL PERMIT �
I hereby affirm that 1 have a certificate oF consent to selF insure, CE-aoeG
dr a certiticzte ot workers'Compensafron�nsurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy themof c.3800.L2b.C.) /f^1 j' �y�
PoIICy N���Ompefly✓,vD V S�J/J•-- FOR APPLICANT N FIIL IN � 'q0 S�/(//Ne�V(-ITV
❑ A��RE53
Certified capy is hereby furnished. �N� New Fesidential Bldgs.8 J�s�_ ,��J g EAC NO. � FEE LOCALIT �l�� � �'
� Certified copy is filed wilh the county Wilding Inspection 1 8 2-Family,Sq.Ft. ��� _ �
de 1me Multi-family Sq.Ft. NEARESi
y�pyy CROSS 5T.
�Date "�� Applicant � Residcnlial Swimming Pools � pwNEH Oa
., . FIRM NAME
� � - CERTIFICATE OF EXEMPTION FROM WORKERS' putlets:Rec_Light_Sw.= - .- � ��� �� �
� � CAMPENSATIONINSURANCE � " aooaESS
Firet 20 �
(This sectbn need not be eompleted if the work invotved by tha Totat No. Add�tional CI7Y v r/� Tel.No. ��S'Cf �
parmit Is tor one hundrad dollars($100)ar less.)
� PLAN CHECK
I certify that in lho performance of the work for which this permit prPUCarrr
- is isSued 1 shall not employ arry person in any manner so as to - —
�become sublect to the Workers'Compensation Laws. L'ghtirg Fiztures Frst 20 ADDRESS
- � � - .� Total No. Addilional CITY Tel.No.
�ate ApPlicant � Fxed ApPliances Not Over 1 HP
NOTICE TO APPLICANT: If,.atter making this Certifkate O� PERMIT � n � Z ,G
���tion,you should beCome subject to the Workers'Compensation
Rarge_Heater_ D.W. _ APPLICANT
�ns cf the L:Lcr Ce^e,yeu muet ferth.vi!h c^mp!y wi!h such Oven_Oryer_WM._ ADDRE55 �v• x ��
provisions or this permit shall be deemed rewked. Top _ FAU _W.H._ CITY �� Tel.NoSy �
LICENSED CONTRACTORS DECLARATION Hood— Fan _Othei_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. —Room Air Cond. — uCENSE OR q� �s_/l/Q
(commencing with Section 7000)oF Division 3 of the Business and RE6.NUN�BER (�'v �
Pfofessions Code,and my licens0 is i0 lull tOfCe and efleCt. ppwer Apparatus 8 Large ApplianCE4 DI57RICT NO. l PF70CESSED BY�
License Number �� Lic.qass � /Q Size 8 Type HP,KW,KVA,or KVAR ILJ 1 - Q
FINAL V
Up to 1 InCL i
v/�Z1��� Date � 3 . Over 1 to 101n�1. �ATE `..ZC-(� ypUDATION �
� Contracta Over 10 to 501nc1. FlNAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY . W
-� Over 100 n'�
B.QP.C.for this reason N
Services,Swbd.,MCC 8 Panelboards � � Z
, � �ate: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V � �6 4 Q�A �
❑ � - � - Over 1000 Amp.or Over 800 V �� � ��$�
Exemption for Reg.Maint.Eiect. 1 tt,,
SINGLE FAMILY - Temp.Povrer Pole S AppurtenanCes • �.1l�yt y�c=i
HOME OWNER-BUILDER DECLARATION �� �Sign with One Branch Cireuit �9, LS t5 I
I roreby alfirm thot 1 am exempt from the ContraMor's License Law
.` '►e lollowirg reason(Section 7031.5,Business and Professions�- Addi�ional Si�n Rranch Circuits
r�
wil�do the work and the stnicture Misa Conduits&Coridudors � � �
❑ I,as owner of the property, Other(See Complete Fee Schedule)_
is not interded or offered for saie(Section 7044,Business , _ , .
and Professions Code).
CONSTRUCTION LENDING AGENCY - � - �� � � , �
I he26y affirm that there is a construction tendirg agency for the ��
perforcnance of the work for which this permit is issued(Sec.3097, -pERMIT FEE � (Sub-Totaq . . .
Civ.C.).
. PLAN CHECKMG FEE . �
Lenders Name ;1
PERMR ISSUING FEE _ ___ . .. V
Lender's Address �
I certify that I hava read this application and state ihat the above TOTAL FEE ���
information is correct.I agree to comply with all CounTy ordinances ,
antl State laws regulating Eledrical wirirg,and here6y authorize
representatives of this County to enter upon the above•mentioned �
- propert for inspection purposes. _.SEE REVERSE FOR EXPLANATORY LANGUAGE �
��2 q 3 �f'7
Signature of Permittee Dale
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