HomeMy WebLinkAboutNo Permit Number (6) WORKERS'COMPENSAT�ONDECLARATION 76A663 �o�a, . APPLICATION R ELECTRICAL PERMIT � �
I hereby af(irm Ihal I have o cerliiicofe oF tonsent to self CE-BabG �
insu�e,or a ceriiiicate of Workeri Compensation Insuronce, COUNTY OF LOS ANGELES I � L�'BUILOING AND SAFETY
or a c hli(i o thereof(Sec.3800,lab.C.) / � �
���s���%�s'7/ A'CL
�ty ryo. Compony. �/✓ FOR A►►LICANi 70 Flt IH JOB il / �
Certified copy is hereby furnished. New Residential Bidgs.8 Pools EACH NO. FEE /DDRESS pf�j� G�NGI/�'7iJ +�•
� Certified copy is filed with the counly b�ilding inspeo- 1 8 2-Family,Sq.ft. s — S LOCALITY L d�Q'^ y '
t� epaftment. / y/� M�I1i-fomily Sq.Ft. CROSSSST. �
--��=�,�--�— L!//`�'�'���f'tT�C/G Residenlial Swimming Pools OWNER OR i
Dole AppiiCOn� FIRM NAME GI ��' i � . o�r�naN,ie3
CERTIFICATE OF EXEMPTION FROM WORKER$' � Ou�lets•Rec_Light_Sw._ �`��
COMPENSRTION INSURANCE " ADDRESS� g � � � �
Thb fecNon n�ed not b�com IN�d if iho work Involv�d b Firs�20 n
( ed p P To+al No. Addinonal CITY � r R Tel. o. . f��
,� fha psrmif It►or ona hundred dollars(SI00)ar lott.) PIAN CHECK
� I certify that in ihe periormonce oi the work for which Ihis APPIICANT �
— permil is issued,I shall not employ ony person in any monner . --
so as to 6ecome subject to the Workers'Compensation Laws. tighting Fiztvres First ZO ADDRESS
To1al No. Additionol ,
Date applimnt CITY Tel.No.
• Fl�ed Appllances Not Over 1 HP PERMIT `
NC �.j0 APPLICAN7: If, a(ter making lhis Cerlificale of AppLIfANT r� � 77�t/C.
E�e .Son, yo� should become subject to the Workeri Range_Heater_D.W._ - - -
Compensa�ion provisions of the Labor Code,you must forih- Oven _Dryer _W.M._ ADDRESS ��� ���
with comply with wch provisions or this permit sholl be Top _FAU _W.H:— y
deemed revoked. � Hood _Fon _Other_ CI1Y��JNv Tel.No.�^j�j�/Gj�
UCENSED CONTRACTORS DECLARATION LICENSE OR C IO
I hereby offirm thal I am licensed under provisions of Chopter 9 Disp. _Room Air Cond.�-- eEG.NUh�eER Cbss. �
(commencing with Secfion 7000)of Division 3 of the 8usiness � power Apporotus 8 Large Appliances DISTRICT NO. P 5�
d'
ond Professions Code,and my license is in full force and effed. p
��p� �/O Size 8 Type HP,KW,KVA,or KVAR� �� U
license Number 6, Lic.Class � Up to 1 IncL FINAL f�
Contrdc�or�1��/C�}'G Date [� ' , Over 1 to 10 Intl. DAiE VALIDATION , �
F-'
O . Over 10 to 50 Incl. F�NAI W
1 am exempt under Sec. Over 50 to 100 Inc. BY a�
8.8P.C.for ihis reoson Over 100 N
Z
- Date: Servites,Swbd.,MCC 8 Vonelboords � —
0-200 Amp.Under 60D V �
Signoture 201-1000 Amp.Under 600 V �
❑ Ove�1000 Amp.or Over 600 V
Exemption for Reg.h1aiM,Elett, /
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �`� �
\ HOME OWNER-BUILDER DECLARATION � Sign with One Branch Circuit z"� j 2$A
r� hy affirm thot I am eaemp�from the Controctoi s Licr.nse qdditional Sign Bronch Circuits 2
law-for the following reoson(SeUion 7031.5, 8usiness and �� � � � �
Profes:ions Code):
❑ I,as owner of the property,will do the work and the Misc.Conduits 8 Conduttors I a..��5 O
s�roc�ure is nol intended or oifered for sole(Section Other($ee Comple�e Fee Schedole)_ ► � /
70d4,Business and Professions Code). �v J�
CONSTRUCTION LENDING AGENCY �
I hereby aifirm thot there is a conslruction lending ogency for �
the performance oi Ihe work(or which this permil is issued PERMIT FEE (Sub-TotolJ
(Sec.3097.Civ.C.).
� PLAN CHECKING FEE � • a 8 2�5.,�j Q'�
lender's Name
� PERMtT ISSUING FEE �
tender's Address �� �
I ceriify thaf I hove read�his opplimtion and slate ihal ihe � TOTAL FEE
obove iniormalian is corrett.I ogree 10 tomply wilh all County .
ordinances and S�ata laws reguloting Electriml wiring,and . .
hereby authorize representalives of ihis Counly 10 enfer upon ' .
/.•he obove-memioned properiy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'-- �°�..� ��`.�,cx. `g�,/
. •f Pe�miuee Date �
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