HomeMy WebLinkAbout1032A (5) - WORKERS'COAtPENSATION DECLARATION a 76a663
, CE�806G(260) APPUCATION FOR ELECTRICAL PERMIT {�
1 hereby atfirm that I have a certificate of consent to self � COUNTY OF LOS ANGELES ' BUILDING AND SAFETY L J
insure,or a certificate ol Workers'Compenm[ion Insuronce,or r � " .
a certified copy thereof(Sec.3800,Lab.CJ -
� FOR APPLICANT TO FILL IN Jpg
� Policy No. Cnmpany EACH NO. FEE ADDRESS �Z� -
, New Residential Bldgs.&Pools
� Certitied copy is hereby furnished:- � � 1&2•Family,5q.Ft. S — S LOCALITY �
❑ � Multi•family Sq.Ft. — NEAREST � �
Certified copy is filed with the county building inspectinn �' CROSS ST
depar[ment. � _ Residential Swimming Pools OWNER OR /�
- � FIRM NAME `afLF►IV
� Date Applicant Outlets:Rec.,�Light�S�v.Z�_ MAIL ,�a �
� First 20 FlODHESS
CERT[PICATC OP CXEh1PTION FROb1 WORKERS' � Total No._j� Additionai CITV Tel No. �
� �COMPfiNSATION INSURANCE � }
. PLAN CHECK a
� APPLICANT �� �
(This sec�ion need not be completed if the work invotved � V
by the petmi[ is for one hundred dollars (5100)or IessJ , Lighting Fixtures First 20 ADDHESS n L Z �
Additional
Total No. •�^ O �
I certity that in the perfnrmance ot the work for which this , � CITV Tel No. �
Fixed Appliances Not Over 1 HP �N� � -�+ V
permit is Issued,I shali nat employ _ persan in am m �er � PERMIT W �
So as to Aecome subject to the 14or et5�Compe lo �vs. � Range_Heater_D.W._ aaal.�caN7 Q, ,
N
Oven _Dryer_W.M._ ADDRESS M Q� Z -
Dste�I'IS��AVP i � ToP _FAU _W.H..— . CI7V�X4h�i�°'4� 6 C'�
ood_Fan _Other_
NOTICE TO APPLICANT:If,after making Ihis Certific�te uf pisp. _Room Rir COnd._ UCENSE OR r
Iixemptian, you shovid hecome subje�t to the Wnrkers' . HEG.NUMBER Q �Cless D' �
Compensation provisions of the Labor Code,you mu5t forth- poWef Apparatus&Large Appliances � DISTa1CT ND. PROCESSED BY
with compiy �vith such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA
� deemed revoked. � � �Q K ��pi� �
� Up to 1 Incl.
FINAL
Over 1 to 70 Ind. DATE � 7� �� VALIDATION
LICENSED CON'fRAC7'ORS DECLARATION ' Over 10!0 50 Incl. "`
i hereby affirm that I sm Iicensed under prnvislons of Chaptet Over 50 to 100 Inc. aY AL .
9(commencing�vith Section 7000)of Division 3 oP the Busi• Over 100 . ��r
ness and Yrokssions.Cade,and my license is in tull farce and �
effect. � � � Services �
o i/�S'47.� -� 0-200 Amp.Under 600 V �
License Number.��,.�.yLLfL Lic.Ciass 2p7.7pp0 Amp.Under 600 V � � � '
�M��s�.�,� ��-��o/ Over 7000 AmP.or Over 600 V
Con ractor .v �Date . �
f10T1E 01VNER•BUILDER DECLARATION Temp.Power Pole&Appurtena�ces � �
I hereby affirm that I am exempt 4om the CnntractoPs Sign with One 8ranch Circuit ��� O�Z A
License Law for ihe foltowing reason(Section 7031.5,Husi- Additional Sign Branth Cireuits . ,
ness and Professions Code): . -
#����• • •2
Misc:Conduits&Conductors - � � �
� I, es o�vner of the property,will dn the work and the Other(See Complete Fee Schedulel— � �'� ��7•5� , '
structure (s not intended or offered tnr sa�e (Sectian � �
7044,Business and Protessions Code). ' r'• •� 7 Jr�c=.>
CONSTRUCTION LENDING AOIiNCY - . - - '
1 hereby attirm thaf there is a construction lending agency -I 2.�Jr�H:� �
for Ihe performance of the work for which ihis permit is pERMIT FEE (Sob-Total) � � �
issued(Sec.3097,Civ.C.).
Lender's Name PLAN CHECKING FEE IOne�Fourth Permit Feel � � �
• LrnJer'sAddress . PERMITISSUINGFEE (fi / �
I cerlify that 1 have read this apPlication and state that thn TOTAL FEE � �G .
above infor ' n is correct.I aRree to comply with all Coun[y , � .
ordinances and S(ate Iax•s regulating ectrical wiring, and � . � %�
hereby au otize representatives Ihis �ounty fo enter upon � � . . %
Ihe abo• entioned prope y r i p �tion purposes. � � SL•E'RF.VLRSE POR EXPLANATORY LANGUAGG � �
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4 � �� ,
Sig atureofPermittee Ua�e �'
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