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HomeMy WebLinkAbout0669A �� WORKERS'COMPENSATIONDECLARATION CEp806G 1078' APpLICATION FOR ELECTRICAL PERMIT f� I here6y a(firm that I h�vo a ccrtificate of consent to self insure, � I , �J.or a certiticate of Workers'Compensation Insurence,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY � � 1{��copy thereaf(Sec.3800,Lab.Q) �•� � SM�1376� IRM .Insurance q p� Policy No. cmpany FOA APPLICAM TO FILL IN ADORE55 v ! G�/�f6� � '� Certified copy is hereby fumished.. . New Residential Bldgs.8 Pools EACH NO. FEE 1 8 2-Family,Sq.Ft. S — 8 LOCALITY C011llt Of L.A. � � Certified�copy is fled with'the count building inspection _ � department. • • Multi•family Sq.Ft, n'Ennesr Lemon C�oss Sr. Date����Applicant j Residential Swimming Poo!s OWVER oR ' � � . .. FIRMNAMECUIIlm1I1$ Electric - CERTIFICATE OF EXEMP N FROA4 WORKERS' �'�n' 74133 EL�Paseo, .St2. 10 �COMPENSATION INSURANCE . . . Outlets:Rec—L'ght—Sw.— ,_„ _ .. . ADOReSS (Thts seclion nead not be camplelad if the work involved by the ' First 20 permit is for one hundred doliars($100)or tess.). Totai No. Additronal c'Tv palm� Desert 7e�.N°G�.g 5 E H 9 O 4 I certily that in the performance of the Nrork for which this permit � . PLaN Ct7EC�ame - APPLICAM is issued,I shall not employ�arry person in arry ma er so as to � become subject to ihe 1Norkers'Compens 'on L L'ghting Fixtures � First 20� ADDRESS- � � Additional � Totai No. _�� qTY � � . � Tel.No. Date.�.�O��APPIicaM Fxed Appiiances Not Over 1 HP NOTICE TO�.APPLICANT: If,,.af �macirg this Ccrtificate o1 PEH�sir Exemption,you should become subject to the Workers'Compensation Range_Healer_ D.W. � nPa�Cnnli CLIIIliR1I1S Eleetrie � provisions ol the Labor Code,you must fo�ihwith comply with such Oven_Dryer_ W.M._ ADDRESS 7�4133 El Paseo, $t0. ��.Q � provisions or this permil shall be deemed revoked . . ..Top- -FAU _ W.H._ � - �- � CITY Pd I_Tfl D@S eI't Tel.No(],9 S G H 9 O 4 110ENSED COPJTRACTORS DECLARATION . Hood—Fan _ Other_ I hereby atfirm that I am licensed under prrnisions ol Chapler 9 _ uCetiSE OH . (commencing with Section 7000)ot Division 3 of the Business and Disp. �—Room Ai�Cond.�_- REG.NUMBER � Glass. Pf0f055i0r15 CAdO,end fny IiCBn50 i9 ifl full}OfCO 2nd�Bif2C1. Powef Appafatu5 8 Lafge Appli3nCeS . . DISTRIGT NO. PROCESSED Y 4 4 73 8 4 Size 8 Type HP,KW,KVA,or KVAR •� �Q License Number Lic.Class C-10 - �� - Up}0 1 Incl. � �� � �� FINAL f(� - -- - - `� Over 1 to t0lncl. DATE If( ��]/,, Con[racrorCuIIITIl1RS Elec. Date � F"`V`r� . . .YALIDATION _. . 0 Over 10 to 50 Incl. U FINAL ❑ _I am exempt und=r Sec. �� � � . Over 50 to 1001nc. gy .___ . . . ._ . _ W 0.8P.C.for this reason Over 100 � N _ _ _ . - Services,Swbd.,MCC&Panelboards � � , ' " - -- "- - -� � � � Z � � Date:�� ' " 0-200 Amp.UrMcr 600 V � �;�=��d_���—��-- zo�-i000 amc:u�ae�soo v - r 0 6 6 9 A -❑ Ovcr 1000 Amp,or pver 600 V Ezemplion for Re9�Maint.EIecL �• •-• • •2 � � SINGLE FAMILY �� � Temp.Power Pole 8 Appur[enances ' • •,.Z ra Jr O _ H06^E OWNER-BU4�ER�EGLARA710N Si9n with One Br2nch Cireuit I herehy aftirm that I em exempt from the Contractor's License Law Additional Sign Branch Circuits - . . • •2 rj, 'Jr Q= lor the foltowing reason(Sedion 7037.5,Business and Prolessions �� Code): � Mis6.Conduits 8 Conductors " " - � - � - - � � ��'3�'8 7 � ❑ I,as owner ol the property,will do the vrork and the structure � is not infended or offered for sale ISection 7D44,Business Other(See Complete Fee Schedulel_ , , and Professions Code1. CONSTRUCTION LEN�ING AGENCY - � �� � � � �- ��� I hereby affirm ihat there is a constrvction lending agency for the • performance of the work for which this permit is issued(Sec.3097, pERMR FEE -- ' ' - (Sub-Totaq � �� � - -�� - - �� � Civ.C.1. . . . ... � PLAN CHECKING FEE � � � �� � � � - - Lender's Name ` PERMITISSUINGFEE . . , O .. . __. . .� _ _ Lender's Address I certify that I have teatl this application and state that the a6ove TOTAI.FEE , , . ,. Information is correct.I agree to compty with zll County ordinances and State laws reguiating Electrical wiring,ard here6y authorize __ ._ _ . _ _ ._ , „ _ . � representxti �of this County to entcr upon the above-menlionetl � � � - - � � � pro .ty 1 �spe��e urposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE . .- _. . . . . . . _ . .. .. .... . � S�� Signa .� �rm� oo Date � . !. ....�'...�1 �l 1.. .. . �... . --.... 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