HomeMy WebLinkAbout1440A ..WONKERS'COAIPENSATIONDECLARATION ' �6A663 ` APPUCATION FOR ELECTRICAL PERMIT q'
� ' 'CE�806G(2-80) u
[ hereby afflrm that I have a certi�cate oP consent to seV j COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certiflcate of Workers'Compensation Insurance,m � �
a certified copy thereof(Sec.3800,Lab.CJ � � /
Voticy No. Company � . FOR APPIICANT TO EA HIN NO. FEE �DRE55 Z�7LaJ �• r�tYQ �L-
New Residential Bldgs.&Pools
� Certified copy is hereby furnished. . � 7&2•Family,5q.Ft. g — S LOCALITV D �.y�G �y.
Multi-family Sq.Ft. N A E T
� Certified capy is filed with the county huilding inspection � CROSS ST
department.. ;Residential Swimming Pools ', OWNER OR /�
� � FIRM NAME /�S�� ��
Date ApPticant' Outlets:Rec._Light' - Sw._ � MAIL /]�
� � Firs[20 ADORESS �Z C• �uY� '�l •
CERTIFICATE OF GXEMPTION FROM WORKERS' Total No. Addilional CITY -/ fp
D. RI TelNo. � E�O },
, COMPENSATION INSURANCE.� - � PLAN CHECK a-
- APPLICANT O
(This sec[ion need not be completed if ihe work involved LightingFixtures �First20 . ApoRESs� '
_ by the permit is for one hundred dollars (5100)or less.). Additional �
Total No. ' p
i rertify that in the pertormance of�the work fnr which this CITv Tel No. • F
ermit is issued,1 shall nnt em )o an Fixed Applianees Not Over 1 HP V .
p p y y person in any manner � � PERMI7 . . W
sn as to become su6ject to the Workers'Compensation Laws. Range_Heater_D.W._ APPLICANT y
. � Oven _Dryer_W.M._ ADORESS N
Z
Date Applicanl � Top� _FAU _W.H.._ . . .
- HoOd_Fan _Otber_ � CITY Tel No.
NOTICE TO APPLICAN7:If,afrer making�his Certificate of Disp. _Room Air Cond._ LICENSE OR _ . �
Exemption, you should become subject to the Workers' REG.NUMBER Cless
Compensation pmvisions of the Labor Code,ynu must forth• power Apparatus&Large Appliances ' DISTNICT NO. PROCESSpppEDJ BV _
�with complY with such provisions or�this permit shall be Size&TYpe HP,KW,KVA,or KVAR �(� �}�/_
deemee revoxed. ✓ . 3 - � _��y-i!�.. .
. . . Up to 1 InCI. FINAL
Ovef 1 to 10 InCI. DATE '
LICENSED CONTRACTORS DHCLARATION ' Over 10 to 50 Incl, �—C{—gZ VALIDATION .
I hereby affirm that I am licensed under provisions ot Chapter Over 50 to 100 Inc. FINaL _
9 (cummencing with Section 7000)of Division 3 of the Ausi- B j �
Over 100
ness and Professions Cnde,and my license is in tull torce and � �
effect. � Services � � �
License Number � Lic.Class '�T� 'P•Under 600 V - .
� � 201-1000 Amp.Under 600 V � .
Contractor Date Over 1000 Amp.or Over 600 V . . �1 4�O�p �
IfOSiG Ol4'NER-BUILAER DECLARATION Temp.Power Pole&Appurtenances � . #� �'� � �2
I hereby affirm that I am eaem0� from the ContractoPs Sign with One-Branch Circuit • � ,
License(.aw for the to�lowing reason(Section 7031.5,Husi• Additional Sign Brench Circuits �� + • • �,� �O ,
ness and Profcssions Code): - •. • 1 1.5�U
Misc.Conduit5&C�nduc[o�s �
.� I,as owner of the property.�vitl do the work and the Other(See Complete fee Schedulel— .
structure is not intended or affered fnr saie (Section . . Q'L Q J�-$2
7044,Ausiness and Professions Code). • �
� CONSTRUCTION LFNDING AOFNCY �
1 h<reby affirm that there�is a constq�ction Irnding aRency . � � ' � �
tor the pertormonce of the work fo/which ihis permit is pERMIT FEE (Su6-Total) -
�issued(Sec.3099,Civ�f��/�l/���1 . ' �
Lender's Name .�l Cl��� PLAN CHECKING FEE (One•Fourth Permit Fee) � .
� Lender's Address PERMIT ISSUING FEE - � l�
1 certity that f have read this application and state that the TOTAL FEE � �
above informatian is correcL I agree lo comply with ali County - � �
orJinsnces and State la�.s r ulating filectrical�widng, and . . �
hereby authorize representati of this Cnunty to enter u�on � � - �
the above•menlione pro or inspection purposes. SEL'REVERSE POR EXPLANpTORY LANCUACE � �
�
Signature o ermittee Uate �
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