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HomeMy WebLinkAbout1098A � WORKERS'COMPENSAIIONDECLARATION 76A663 �oi8� qppLICATION FOR ELECTRICAL PERMIT � {� CE-BO6G I hereby alfirm that I haVe a certiticale ol consent to self insure, �� i ➢r a certificate of Workers'Compensafron Insurarrce,or a certi�ied COUNTY OF LOS ANGELES BUILDING AND SAFETY �`�/copy thereoi�Sec.3800,Lab.CJ ` PohCy No. � ' Cpmparry PoR APPLICANT TO FllL IN DDRE55 �J�S �d. �e.�✓�dN ❑ Ceitified copy is here6y furnished . _, . ,. New ResideMial Bldgs.&Poois EACH NO. . FEE � '� 1 8 2-Famil IOCALITY . Certified�copy is fled with�Ihe ca ty buiid'ng Insfiection Y�SQ.F�. g — � � de artmenL . . �� � Multi•family Sq.Ft. — � � NEAnEST /�� � Residential Swimming Pools , CROSS S7. L�����Y' Date.��'�Applicant� � , OwNEaOA � � . FIRM NAME �U�= ')/� , 'CERTIFICATE OF EXEMPTION F WORKERS'� � ��A � � - ,COMPENSATION IN ANCE - �, Outlets:Rec L'ght Sw• I�7 t ' oDReSS � (Thle seclbn need no!be eompleted if the urork Involvetl by the �6� Flrst 20 � � Total No. Additional CITY � Tel.No. t� permit is for ane hundred dollars(5100)or Iesa.) . � I certify that in Ihe perlormznce of!he vrork for which this permit PtaN CnECK is issued,1 shall not emptoy any person In ary manner so as tv � P.PPLICAM J become subject to the Workers'Compensation Laws. Lighting Fixtures Frst 20 �- - � L ADDRESS - � � � � � �� � Total No.� Additional CITY ' � � ' � Tei.No. Oate Applicant �- � . Flxetl Appliance9 Not Over t HP pERMiT NOTICE TO�APPLICANT; I}, af!er making this�Certificate o1 APPLICnNT � 'U/L %"� � Exemption,you shouid become subjed to the Workere'Compensation Ran9e_Heater_ D.W. c � nG provisicre oF the Laher Cede,�rou must!crtk::ith comFly rri!h such O�en_Pyer_ W.�d._ ADDRESS � �, �� es� j provisions or this permit shail be tleemed rewked. � 7op _.FAU._ W.H._ � �Ry� A����� -Tel.No.� .�'j ��LICENSED CANTRACTORS�ECLARATION� . Hood_Fan _ Other_ LG� I hereby affirm that I am licensed untler provisions Of Chapter J DISp.'—ROOfiI Alf COfld. _ ' LICENSE OR Clzss. }+ (commencing with Section 7000)of Divisbn 3 of the Business end REG.NUMBER ��"� -- / ROfe55i0n5 Code,and my IicenSe is in Full fOfCe and ef(eCL aSTRIC7 NO. P(vOCESSEo BY ..Povrer APParalus 8 Large ApPliances -. _ . . . . .. .� � � Size 8 Type HP,KW,KVA,or KVAR � � License Number���3�� Lla Class� � � ' � Up to 1 Incl. � � � FINAL 7 � �� � � � Contrect ��Date�� / Owr 1 to 10 Incl. DATE Q Z Qj/S/.-... .. VALIDA710N . 0 v f--- Over 10 to 50 Incl. FINAL O U ❑, I am exempt untler Sec. .. Over 50 to-100 Inc.. gy .. W BBP.C.for this reason Over 100 N ._ ____ _ .... . ' 'Services,Swbd.;MCC 8 Panelboards -- "-�-� �� � � � � - .--�� -� � � -- � Z Da!e: 0-200 Amp.Under 600 V � Signature 201-1000 Amp.Under 600 V- - ' "- � -- � - - � ��� � � . - _ . . . .. . . . . ... . ❑ �- Over 1000 Amp.or Over 600 V • Ezemption for Reg.Maint.Elect. - � - �•-��-�-- -- - � � � � �� - SINGLE FAMILY - - Temp.Pov+er Pole 8 Appurtenances - �� �9.8 a HOME 04'lNER-QUILDER�ECLARATION Sign with One Branch Circuit N ' � � � '2 I herehy aAirm that I am exempt from the Contmc!or's License Law lor the fonowing reason(Section 7031.5,Business an0 Professions ��=����'al Siyn Branch Cira:•.:o- �� � . . . . . . .I a e��5�.. Code): �• . .7�.J�_ . ❑ I,as owner oF the property,will tlo the work and the structure Misa Conduits&Condudors� � � � � O�S�O.'�-S 7 . � is not intended or olfered for sale(Section 7044,Business Other(See Complete Fee Schedute)_ , and Professions Code). CONSTRUCTION LENDING AGENCY �- � � - � -- � I hereby affirm thaf there is a[on5lmdion IeMirg 2gency For the per}ormance of the work 1or which this permit is issued(Sec.30�37, PERMR FEE - (Sub-Totaq -- s � � � � - - -- - ----� Civ.C.1. PLAN CHECKING FEE� --- � �� � - � � �- --�- . � Lenders Name . � PERMIT ISSUING FEE -. - -_-- _ . ., .../D . . Lender's Address � I certiry that I have read this application and state that the above TOTAL FEE , ._ _.. , . � , � information is correct.I agree to comply with all County ortlinances antl State IawS regulating ElecViCal wiring, antl hcreby authorize .., � � representatives o1 this County to enter upon the above-mentionea . � � - � � �� - � propert insp^��f pur oses. � / � �/ �{ /� -� - SEE REVERSE FOR EXPLANATORY LANGUAGE - - . . _.. . ✓ �J�:/ ',natur 1 ermrttee Date ' �, . -- , �..: _.�.... • . . _.. ' . ' __,__._' . .- --� __-.' ----'- - -- - - -.' -_." � V.�� ' i. I I � �V! � � I � i .. _ i � /�• i i I :i• , j � ' + ! �' r�, I�, � / � ! �!' � . --, � ��, t, . i ',.Jii' � ' � I, i - � f i Y' � � � ;C � � ' _ ' ` ' • �' � i � _. i � ; _ i �' � i'/� i.- � L" i ' . 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