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HomeMy WebLinkAbout1300A (7) WORKEFtS'COMPENSATIONDECLARATION 76A663 +0�8� APpLICATiON FOR ELECTRICAL PERMIT {� � 1 hereby affirm that I h�ve a Cwtificate of ronsent to self insu�e, CE-806G � or a certit�cate ot Workers'compensation�nsurance,or a certired COUNTY OF LOS ANGELES BUILDING AND SAFETY wpy thereeF(Sec.3800.Lab.C.) ..�` • Polity No. � COinpany�pl��-%�- �FOq APPLICANT N FILL IN � - J09 �� ❑ .Certificd copy is hereby fumished. EACH NO. FEE AD�RESS ��� � �((.�y� \�� New Residential Bltlgs.&Pools �j�►�Certitied copy is�Hled with the tounty builCing inspection �g 2-Family,Sq.Ft. 5 — S LOCALITV. � , . �`–� �department. . Multi-family Sq.Ft. — NEAREST . CROSS 57. � " � Residential5�mmi Pools - "� � Date�Applicant �� � �^9, pwn;tp pl� . , . .6[,.N��! . ..... .' � � FIRM NAME a . , CERTIFICATE OF EXE6".PT10N RO WORKERS' � p�l��s:Rec VLiyM_$W,_ MAIL . .. . , COMPENSATION INS ANCE - - . . ADORESS 1 (Thls sectbn need not he comdeted if the work imolved by the First 20 permit is for one hundred dollars($100)or less.) . . Total No. Additanal CI7Y Tel.No. I certity thst in[he performance of the work for which this permit . _ . __ _ P�nN cHecK �_ r �is issued,I shall not employ zrry Derson in any manner so as�o - A�'��M �O 1 – become subject to the Workers'Compensation Laws. , Li9hting F.tures First 20 AODRESS' (f � r � ' • � . Total No. Additional - ��� CffY Tel.No Date Applicant � Fxed Appliances Not�Over 1 HP � NDTICE�70 APPLICANT: If, alter. makirg this Certificate ot PER�niT Exemption,you should hecome subject to the Workers'Compensation Range_ Heater_D.W. aPauCnNi provisions oi the Lnbo�Code,you must fortMvith comply with such Oven_Dryer_ W.M._ � ���� A�DRESS � ' - provisions or lhis permit shall 6e deemedrevokee. -� Top___FAU,_ W.H._ UCENSEO CONTRACTORS DECLARATION � �� � � ��TY -" "-� � ' � �Tel.No. � / Hood—Fan _ Other_ �!� 1 hereby a%irm thet I 2m IiCenSetl under provi5ion5 of Chaptef 9 UCENSE OR /� (commencing wilh Section 7000)of Division 3 of the 8usiness and --Disp.�—Room Air Cond. _ aEG.Nunnaea � �`? � � ���% �� Wofessions Code,and my license is in lull force and effect � po,���ApOaratus&Large Appliances _ _ Dis7A�Cr No. paOCESSEo av } G � Size 8 Type HP,K1V,KVA,or KVAR ,a p: License Numbet_�j 1���_Lia Class�•� � -- Up to 1 Incl. - � FINAL� � - - � .� V I Over 1 to f0lncl. DATE 2,. ' Contraclor�nLl�1.�.ti.�� ' Da[a���- Over 10 b 501nc6 ��� ._ . VALIDATION O � - - avAL U I am exempt under Sec. Ovcr 50 to 100 Inc. B.SP.C.for this reason Over 100 �� � - � � a Services,Swbtl.,MCC A Panel6oards N -� - - Date: 0-200 Amp.Under 600 V � ' � Signature - 201-1000 Amp.Under 600 V� � - .... . . , . ❑ � � ��-� Over t00D Amp.or Over 6D0 V Ezemptbn ior Reg.Maint.Elect. . _ . . .._....... . ._ � SINGLE FAA+.!LY� ��--- �� � Temp.P�x�er Pole&Appurtenances HOME OWNER-BUILDER DECIARATION �Sign with One Branch Circuit � �� - � �- - � I here6y a(firm ihat I am exempt from the Conhador's License Law � tor�he following reason(Sar,tinn 7031.5,Busi�ss 2nd%ot?55i!wi5 - �ditiOnal Sgn Branch Cirevits Code): . . . . _ . . ._ . . . . . � - Misa Conduits&Conduclors ._ . . , .. , , � I,as owner of the property,will do ihe vrork and the structure - n is not in!ended or oHered for salo(Section 7044,Business other(See Comp�ere Fee Schedu�e)_ ='�'v O,O A� � and Professions CodeL � � -� �--� � , � . . . . #� � �'.�.�� CONSTRUCTION LEN�ING AGENCY � - - - - � � � / a 3 Q 5 0 I hereby affirm that Ihere is a constmction IeMing agerKy for the performance of ihe wwk ior which this permit is issuetl(Sec.3097, - pERM1T FEE (SubdotalJ Q (� . _ _ . _. � a � x c��.c.�. 3 Q 5 0� PLAN CHECKING FEE .. . . . _ _ Q 0 Q 2_$7 � Lender's Name � � - .. PERMR ISSUING FEE , _.__ . . J!J LendersAddress � � �b� � -" � ' - � -- - - I certity that I heve read this application aM state that the above TOTAL FEE � information is corretL I agree to mmply with all County ordinances - � � �- - - - � � � - - and State laws mgulating Electrical wiring,and hereby authorize . representatives o1 this County to enter upon the above•mentioned ��-� �� " " �- '� � - � � � � --� - �.� .. property for inspection purposes. . .SEE REVERSE FOR EXPLANA70RY LANGUAGE �._�—d 1 Signatu - Permitree Oate ":.... ..... . .. . -- . : � -..� �--- , , �� ..__ --- -- -. , ._---- �-- ------- - I j i .....I.. i ;,." i i - ' 1 � ; � � �: .' . i ' : � i � - j i ' 'I I I., l � _ � i • " �� . ' '� .., � � �..1 S I � � ��, ,� I � � ' I i � � �� � j i I 'i .. . . . �' . ! ' ��. - �., � � � � _� I . f I i ' ��� ' . I . ' �� I .i �� . . _.._ '__ :_ . i . � �. : � '. � . : . � � � � ` I ' i . .. � ,- . t • . � � : . ! � 2 T C 'U T. � � ' -1 ° _,- �,�. 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