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HomeMy WebLinkAbout1769A WORKERS'COMPENSATIONDECLARATION 76A663 ,a�e, qppLICATION FOR ELECTRICAL PERMIT � 1 hereby alfirm thal I have a CertifiCale 01 consent[0 5elt inswe, CE-BO6G w a certifcate ot Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY �� copy thereoi(�.3600.Lab.G) � ' .�; . PoIiCy N0. � ��� Comparry � FOR APPUCANT TO FlLL IN �� '`� / , _ � ❑ Certified copy is hereb lurnished.��,` EACH NO. FEE ADDRESS � ��� �� �:='� �-� Y New Residenlial Bidgs.&Poois � CertiFied copy is filed with the county building inspection 1 8 2-Family,Sq.Ft. 5 — S LOCAUTY + ;,.--:�� . •� .. depa�tment. % Mu��i-family Sq.Ft. — NEAHEST -�.r :' . . ,- ! , . /•�� ° "� R=sidentiat Swimming Pools CROSS S7. ! � Date�� � � � Appli[ant � OWrvER OR f � FIRM NAME � � CERTIFICATE OF EXEMPTION FROM WORKERS' putiets:Rec—Light—Sw.— Ma�� 1 i. ; � � �, / /�' � ' COMPENSATION INSURANCE A�DAE55 �/ �� ' '(This nectbn need not be completed it the work involved by the First 20 . .� permit is for wie hundred tldlars($700)or leas.) Total No. Additional GTYI� , f Tel.Np. I certify that in the performance of lhe vrork tor which Ihis permit ��j�M K - is issued,I shall not employ arry person in any manner so as to — become subject to the Workers'Compensation Laws. L'ghting Fixtures First 20 ADDRE55 Adtlilionat ' Total No. CITY Tel.No. Date � ApplicaM Fized Appliances Not Over 1 HP PEHMIT NOTICE TO APPLICANT: If, after making this Certificate of ' �,� ,�" Exemption,you should become subject to the Workers'Compensatbn Range_ Heater_D.W. _ AP���P'�;- '. provisions of the Labor Code,you must forthwith comply with such Oven_ Dryer_ W.M._ ADDRESS{-. ". �i +'r ` � ' provisions or this permit shall be deemed rewked. � Top _FAU _W.H._ � ' �,� • � LICENSED COMRACTORS DECIARATION Hood_Fan _ Other_ GTY fj!.- �.•... ;j": ; Tel.No.� .:.'/_ 1 here6y alfirm that I am licensed untler provisions ot Chapter 9 . LIGENSE OR � � _ Disp. —Room Aif COtld. — REG.Nl1MBER I � ��-� Class.�.� (commeneing with Sec[ion 7000)of Division 3 of the Business and � �' ^"� Powcr Appaiatus 8 Large Appliances DISTRILT NO. PFiOCESSED BY Pto(esslons Code,and license is in full torce and effect. U �.J � Size 8 Type NP,KW,KVA,or KVAR � r 1� �,,��` W License Numbei��' '" 'Lic.Class �� � Up to i Inci. � FINAL J � •' ,i �.. - t�, // Over 1 to 101ne1. DATE VALIUATION � Contractoi '� '� � '�� Date�� � �% � � Over 10 to 50 IncL FINAL ❑ I am exempt under Sec. Over 50 to f 00 Inc. gy d r Over�OOr. . '�� - O - B.&P.C.for lhis reason . . .�-, �- . , . . � � � Services.Sv�bd..MCC 8 Panel�rds;�.' � Date: � 0-200 Amp.Unde�600�V�-� � � Signature 201-1000 Amp.Under 600 V ' Over f000 Amp.or.Over 600 V �:,E.emption for Reg.Maint Eletl. SINGLE FAMILY Temp.Power Pole&Appurtenances .. HOME OWNER-BUILDEF OECLARATION Sign wilh One Branch Circuit I herohy afl�•m in�!I 2m erP„mt!rmm thP Centrallor's License Law tor the(otlowirg reason(SeCtion 7031.5,Business and Professions Atltlrtional Sign Branch Circuits . , - Code1: -..�:.i,Q�r;� Misa Contluita&Conductors / � � � �� ❑ I,as owner of the property,will do the vrork and the structwe p�her(See Complete Fee Scheduie)_ ', ��'�'+''��F�' - is not intended or otfered for 5ale(Section 7044,Business „ and Professions CoCe1. ► �f;�;�•,.�,L�.,�f'r CANSTRUCTION LENDING AGENCY �" � ' � I heleby affirm that there is a construction lending agency tor ihe `�"'�'.i'�."�;4'. performance ol the work for which this permit is issued(Sec.3097, pERMR FEE ISub-Totap � i^•��:l: a,,.c.�. . �`'��c..,u f: ��\ � ` . PLAN CHECKING fEE . • Lender's Name � _� � PERMIT ISSUING FEE � � Lender's Address � I certify that I have read this applicatbn aM stale that the above TOTAL FEE '�.,� �{` . information is correcti�l agree to comply with all County adinances . antl Stale laws regulating Electrical wiring,aM hereby aWhorize ' , � representativeg•o1 this CouMy to enter upon the above-mentioned properry fyrfnspec[ion purposes. - � ���,_��� SEE REVERSE FOR EXPLANATORY LANGUAGE ,�� ' Signature of Permdtee Date .. ,� . 1_. ... . ._.� 4, .�.��. . . �I._ ( � ----t_ ._�_�. _. _ ,j I f,.i . `i' i I ( I i ' i � � i I I , I 1 � . , : . ; ' j ' ; ' : i � !� I ( i ' i ' ' I ' � 1 �':� I � � � j � � � . l -- � : � ' ' ' ; j i ' • � ; I - � , i i �i . . . i � , i . �, -•� � � � � j - � ' I ! ! I � i � , n _.' � j � i i I I i � ' � ; ,i . . - - -i -- �---} � . i i i I i ! ,� ,. � I I � � i � I i : I ' � � _ . . � i i � I i ; ! � ) � I ., � � � ' ' I ' ' � •_ !,. � i i � ,�' . . ' ..� . i . . ' � � . 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