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HomeMy WebLinkAbout1311A WORKERS'COMPENSATIONDECLARATION 78A683 70/81 qppLICATION FOR ELECTRICAL PERMIT � {� I hereby aff;(m thahl have a certifiCate of consent to self insure, CE-so6G w a e�rtiticate ot Workers'compensatron�nsurance,or a cerfieed COUNTY OF LOS ANGELES BUILDING AND SAFETY u copy thereof�Sec.3800.Lab.CJ � ❑�Ceftified COpy iS hefeby fuprn hEd. FOR APPLICANT TO FIEACH NO. FEE JOB � �` ���I� �"• AD�RESS , , _ New Fesidential Bldgs.8 Pools � _ g LOCALITY����� �GG� �� Certitied copy is filed with the county builtlirg inspection 1 8 2-Fami�y,Sq.Ft. depa�tmeni. - . . Multl-famiiy Sq.Ft. — NEnaeST ��� Residen[isl Swimming Pools Cnass ST. "'� o�te npvrcant w+tiEa oa K F MIG� � ��E[�- .� CERTIFICATE OF EXEMPTION FROM WORKERS' . 5 - _ FlRM NAME COMPENSATIONINSURANCE . � Ou11e1s:Rec_Light�- Sw.� --�� `. � ' , � qDoneSS �'� wy"�I� 7��� First 20 J (This sectlon need not 6e compteted it the work involved by the J� CITY U+J�M���• t2 Tel.No. permit Is far one hundred dollars(5100)w Iess.J , Total No. Additional I certify that in thr.performance of the r which this permit Pu4N CHECK , .i3 i55ued,1 5hall not employ any pef n a rt12 f SO 2S t0 ����- ' '' APPLILpM- �� ' become subieet t the Workers'Cam s ' � L'ghting Fixtures First 20 — `, ADDRESS � ��� .. � ���-� . Total No.� �ditional xDate Applicznt .: . . CITY i Tet.No. �J NOTiCE TO AP LICANT: If, after n'g this rtificate of Fzed Appliances Not Over 1 HP �EqM�i ���� Exemption,}rou snould become s ' to he Workers mpensation Range_Heater_ D.W. _ AP��M .pmv�cions ol th?Labor Cod=.yeu m��s� orthwith c^m^,!Y w'!h�,rh . ... Oven_ L4y,e•_ N/A4._. . . AL+OP.E55 �^�.y1(_^ . . �provisions or this permit shall be deemr,d mvoked. - Top —FAU _ W.H._ UCENSED CONTRACTORS DECLARATION � CITY � � � •Tel.No. � Hood— Fan _ Other I hzreby affirm that I am licensed under provisions ol Chapter 9 � ULENSEOR , (commencin9 wilh Section 70001 of Division 3�of the Business and "- - Disp. —Room Air Cond. REO.NUMeER�. � � � � �� Class � PfOfessiMs Code,and my license is in full torCe and eff�. DI57RIC7 NO. MiOCESSED BY Power Apparatus&Large Appliances Size 8 Type HP,KW,KVA,or KVAR /� � � , O License Number Lic.Ciass - . � -Up to 1 Incl. - �� ' - � � � - � FINAL � � � �� � � � - -- 0 ... . Over 1 t0 101nC1. DA� ��2��(�1� VALIDATION Q � Contractor � � -Date � � � � Over 70 to 50 Incl. � • �-- FINAL ❑ �am exempt under Sec. Over 50 to 100 Inc. gy _ - W 68P.C.for th�s reason Over 100 - � � � N � Services,Swbd.,MCC&Panetboards� - �� - � �- - . . Z ........ _.. . Dzte: � 0-200 Amp.Under 600 V - — Signature - 201-1000 Amp.Under 600 V � �� � � .._. -� � � ����-- � - - � �� Over 1000 Amp.or Over 600 V ❑ Exemp£ron lor Reg.Maint Elect. . . .... .. . .. ... . . . .. . __ � . . . ..'_ ._.._ ��� � ��� � SINGLE FAM!LY - � Temp.Power Poie&Appurtenances -�1 3 1,1 A HOME OVRdER-BUILDER DECLARATION Sign with One 8ranch Circuit - � � � I hereby alfirm that I am exempt from the Contracbr's License L�w p�,�������c��,�R,,.,,,h C.ir^_�?!s �� � � � �2 lor ihe foBowinc�reason ISecfion 7031.5,oushiess and Prolessions-� � �� . - _ . Code): � � �3 2 5 0 JCI Misa Conduits 8 Conductors '�. � � ... . . . . . •. . �� I,as owner of ihe property,will do the vrork and Ihe structuro .is not intended or offered tor sale(Section 7044,Business Other(See Complete Fee SGhedule)_ , ^ °.3 2.J l�c=i and Professions Code). � - " - � �- � - - 0901 —8£3 CONSTRUGTION LENDING AGENCY - � _ . - _. . _ _ _ _ _ _ I hereby zffrm that there is n construction IenCing agency for the performance of the work for which this permit is issued(Sec.3097, pERMR-FEE ��� ���-� ��� � . (Su6-Total) � .. . Civ.CJ. � - - _ PLAN CHECKING FEE . . . _ . Lender's Name � - � � - � � . PERMIT ISSUING FEE V Lender's Address � � - � I certily that I have read this application and state that the above TOTAL FEE informzti is ct.I agree to compiy with all County ordinances � � � � - � � dnd S t la�s r gulafin E(ectrical wiring,and hereby authorize , ' represe 1.ti s oi ty to enter upo the above-mentioned ''�" " �" - � —� - � � - �� - � � - propert � urpo_ �- _ SEE REVERSE FOR EXPLANATORY LANGUAGE , . / I i _ . . . . . . �Signat� e itteP te � / !' ._�:,.... �. . ...�. . __.'.--- --- - ._.__-•- ----- ---� . . � i j � � I I � j il � V'A� I ' I i " . ' � ; � � ; .. . � I � , , • ' i ; I j : � i ! I . i . .. i i I ; i i � ' ' ! ' I ' �- � � ' -,i : ;, .. ' I i ' ' I I _ �_ . `_ 1 � ! . j " ; ' I I � � _- i ` i � ic� � , _ i i _.. _ . ' I --- --- -- � I i T � �' ,T� -` '�- C !T, i __ ` �.'. � � _ � _ � /. I ' I. _. O � C � � 7] �. v �: �i . . . , � ' . � r -f r�j C � Ll � Zl. , .�. I .. � I.-" . { y� � L� S , � '''� ~ I' _. 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