HomeMy WebLinkAbout0597A WORKERS'CAMPENSATION DECLARATION 76A663 �o,e,� � qpp��CATION FOR ELECTRICAL PERMIT � {�
� I her¢by alfirm lhat I have a Gefti}iC3f0 Of COnSen�l0 5etl in5ure, ��BO6G .
or a ceni(icate of Workers'Compensation Insurance,or a certitied COl1NTY OF LOS ANGELES BUtLDING AND SAFETY LJ
copy thereot(Sec.p3800.Lab.C.)
PoIiCY NO.� /a�� Company�ND✓S%n//q'�'' FOfl APPLICANT TO FILL IN J08 ` /
,❑ Cer6fietl copy is hereby lurnished. �N� New Residential BtOgs.&Poo /y�� �C NO. FEE ADDRE55 ,�J.LQ/✓(T(/ �',p,/Q/1•
�� Certifietl copy is filetl with the county buildirg inspeclion 1 8 2-Family.Sq.Ft.�C� S = S LOCALITY �
2 rt 1. Mulll•�amily Sq.FL NEAREST
�-yy�'���,, CROSS 5T
Date��� Appticant� �' """"�- �sidential Swimming Poo�s owr�ER oR
' � FIRM W1MEB i� '
� CERTIFICATE OF EXEMPTION FROM WORKERS' � . t�7qi�
�COMPENSATION INSl1RANCE ���ets:Rec—Li9ht—Sw.— pppqESS� � y ��
(TAia seclion need not be compieted it lhe work inro�ved by the First 20 �
permil Is for one huntlred dollars($100)or less.) Total No. Additional CIT �'T�- ��y� el.Nog
I certify that in lhe performance of the work for which this permit PUW CHECK
is issued,I shall ra[employ any person in any manner so as to ����
become subjecl to the Wwkers'Compensation Laws. Lightirg Fiztures Firsl 20� AODRESS
� � Total No. Additional. _ �
Da[o ApWicant � qTY� Tel.No.
.C`^TICE TO APPLICANT: IF, after making this Cerlilicate of Fixed Appliances Not Over 1 HP pEHMIT ���ij�`` C�'4 '
.� .ption,you should becoma subject to the�Porkers'Compensation RdfgO_FiBd�Of�_D.YY. APPLKANT [�� /[x//e/�-
. pi.,visions of the Labor Code,you must forthwith comply with such Oven_Dryer_ W.M._ ADORESS .� ���
provisions or this permit shall be deemed revoked . , Top _FAU _ W.H._ � /���
�� IJCENSED CONTR4CTORS DECLARATION .. Hood�Fan _Othcr_ CITY /�/� 9�'v Tel.N
I hereby affirm that I am licensetl untler provisions oLChapter 9 Disp. �Room Air Cond. — UCEn7Se Oa ,q�p .
(commencing with Section 7000)of Division 3 of tho Business antl REG.NUMeea ci�/O �
PfOfB5510f15 Code,Zfld my GLense i5 1n�ull IOfCe afld BfIBLt. , DISTRILT NO. PROGESSEO BY
Power Apparatus&large ApplianCes q O
/,n�,�9 C, /D Size 8 Type HP,KW,KVA,or KVAR \� Cx p�1'�
License Number 7%V��� Lic.Class - Up to 1 Incl. FINAL / � � V
���Z�c/ �/�— Date y� oYer i io 10 1ncl. OATE �o(3!/�� o
Contracto� Over 10 to 50 1ncl. . VnLIDA710N
FINAt V
❑ I am e,empt untler Sec. Over 50 to�1001nc. . . BY � w
, B&P.C.for Ihis reason Over 100 �
. Services,Swbtl.,MCC&Panelboards - , - Z
Date: 0-200 Amp.Under 600 V
s�9oat�re zoi-�000 nmv.uoder eoo v �p 5 9 7 q
Over 1000 Amp.or Over 600 V
� Exemptan for Reg.Main4 Elect. � � � $�. . . o .2
� � � SINGLE FAMILY . .7emp.Power Pole 8 Appurtenances � • •9 2��
HOME OWNcn-6UiLD'cR GECL:.R:d16W Sign wrth One&anch Circuit
� �by affirm lhal I am ezempt irom[he Conlractor's L'�cense Law qdditbnal Si n Branch Cirwits� � - • • •
_.ie foliowing reason(Section 7031.5,Business antl Prolessions 9 G 2 9 0�
Code):
� M�sa Conduits&Conductors 0 a 0 S—8 8 -
I,as owner ol the property,will do the work and tha strucWre
_ is not inlended or otfered fw sale(Seclion 7044,Business Olher(See Completo Fee Schetlule)_ .
and Professions Code).
CONSTRUCTION LENDING AGENCY . �
I hereby alfirm that Ihere is a construction lending agency lor the
performance oF ihe work tor which this permit is issued(Sec.3097, PERMR FEE - � (Sub-Total) � � - -
Civ.C.).
PLAN CHECKING FEE
Lender's Name
- PERMIT ISSUING FEE - /(� .
Lender's Address � �
I certify that 1 have read Ihis application and state ihat iM above - TOTAI FEE �
inlormation is correct.I agree to wmply with all County ortlinances
and State laws regulating Electrical wiring,and hereby authorize . . . . . �
representatives of this Counly to enter upon the-bove-mentioned �
�.��p rfy IOf InSDeC1i0�Wrposes.
� �/� - SEE REVERSE FOR EXPLANATORY LANGUAGE - .. . ..
✓
Signature of Permitlee Date
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