HomeMy WebLinkAbout0876A (4) �. NJORKERS'COMPENSA710NDECLARATION �,q�,3,e� qpp��CATtON FOR ELECTRICA! PERMIT �
� hereby affirm that I hove a certificate of consent to self ,�.�
i'nsure,or a certifimte of Workers'Compensation Insurance, CCIUNTY OF LOS ANGELES DEPT.OF PUBLIC WQRICS
or a cartiffed copy ihereof($ec,3800,Lab.C.) -
Policy No. Company iOR APPLIGNT TO FILL IN . �pg .
�Certified copy�is hereby fornished. New Residential Bldgs.8 Poois EACH N4. FEE ADDRE55
IQCHUTY
Ce�t7fied copy is fifed with the w�nty building inspx- 1&2-Fomity,Sq.Pt. s — b �
�tion department. Mulri-family Sq.Ft. � �ARE57
. Resideniial Swimming Pools ��u ST. Y✓jI`'
Da�e App{icanF OWNER OR
FIRM NAME
- CERTfFlCATE OF EXEMPTION PROM WORKERS' putlets:Rec�Light 3 Sw� 'W"��
� -- �CAMPENSATIONINSURANCE ADDRESS (,�G .v4` GJ
(Thit wclion twoA not 6t tomplabd iE tba work iavu{rvd by t, Firo6 20 CITY
� th�parm{t{s for ona hundrod dol{an{SIW)ar bss.j Tofal No.JJ� ,qddifiorw4 O�t.Y�/j/Jn.Tei.No.)/�J��/'� �
I certify}hat�ir�.he per4armance�of�ihe wwk for-which this PLANCHKK
APPLICAM
permit is issued,I shafl not employ eny person in ony menner
so as to becom�ed to the Wor ers Gompeototlan tows. Lighting Fixtures Pirst 20 ADDRESS �
..loksl No.� Additio�a! �
- ---. .__ __. -___-. CITY Tel.No.
6ote - -�. �- Applican ' . . . . . ..
� NOiICE TQ APPLICANT: If, aking this Cenificate of F&ed Applionces Not Qver 7 HP p€p�� —
Exemption, you should c subject to the Workers` � Range— Heater—D.W. _ ���n� � G �! ,.
Compensaiion pravisiorts o t e tabar Code,you must forth- Oven —Wyer —W.M._ qpQR� ¢� �����y �pU�
wifh comply_wifh such pcovisians ar tbis permit shall be Top �FAU —W.k.—
deemedrevoked.�- - � � � Hood —Fan —Other_ CIn f1�TeI.No. �,�_3�
��� LICENSEO CONTRRCTORS DECLARATION Li�NSE.OR.._.
i hereby nffirm thaf I am litensed under provisions oE Chapter 4 ��sp. _�Room Air Cond. _ . REG:NUMBER - - Ctass.
(commerrci�-wifh Settion T060)of Divisien 3 of the Business- power Appprptus&ldrge Appliances - DISTR{CT NO. f/ pRp{,E$�Q gy }
- andProfeuio�sCoda,arn{mylicenseisinfu!lfortearadaffect_ � Size&Fype HP,KW,KYA,ar KVAR � k � �
license Number ���'�-�J 7 Lic.Clau � Up to t lncL � fINAI U
Canfi�tor.`�r`�C ��'f�-note�..�. 9I . . Over 1 to iQ Ind. DA� _. ,�i- � VALIDATION �
❑ --- E7ver 10 to 50 Inct. . Q
t am exempt under Sec. Over SO to ip0 Int. gy�� �
B.&P.C.for this reason Over 100 ...__...._..- ..- a
Services,Swbd.,MCC&Panelboards � �
�+te: �
- - 0-240 Amp.Under 600 Y �
Signaturo � . - 2p1-IWOAmp.UnderGQOV
Q - - . Over 7000 Amp.or pver 600 V
Exemption for Reg.hM1ainl.EleU.
SWGLE FAMILX � Temp.Power Pob&Appurtenances
HOME OWNER-BUILD€R DECLARATION u�� l.(7�;
-7 herebp pffirm thal l am exempt from the Cootractor's License Sign wifh One Branch Circuit
Law for the following reason(Sedion 70.?I.S, Business�and �4dditional Sign&anch Circuih #e ' • s e�
Professions Code}:
"�.1,as owner of the property, will do the work and the
Mitc.Conduits&Conductors 1 ' °���v'C
� strodure is not intended or offered for wle{Section 7044, Other(See Complete Fee Schedulej_ � � •• �c�f�l:l�a
� Business ond Pro€essions Code). . �
CONSfRUCTiON IENDING AGENCY Q�u� �"v ii
1 hereby offirm that there is a construttion lending agency for -
the performonce of tbe work for which this permit is issued PERMIT FEE (Sub-Total) ��j
(Sec.3097.Ci�..C.). . .
- . PLAN CHECKING FEE
Lende(s Name -. .:. . . .
- PERMtT lSSUING FEE �D
Lendei s Address
I tertify that 1 have read this apptication and state that the �fOTAt PEE � �
. above informatian is corcect.i.ogree�o cemply with all County - .
ordinances ond State laves regulating Electrica�wioing,and
hereby outhorize representa�ives of Ihis Caunty to enter upon
the abov -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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