HomeMy WebLinkAbout1657A � WORKERS'fOMPHJSATtpN-0ECtARAiION �- �a'� ����81 � APPLlCAT1411! FQR ElECTRICAl. PERMlT �
- � 1 bereby affirm that i have a certifiwte of consent to self GE-806G
insure,or a cerrificate of Workers'Compensation tnsumnce, COUNTY Of LOS ANGELES BUILDING AND SAFETY
or a certified�mpp thereof(Sec.3800,Lab.C.} � �
P❑alicy No.j�QD�ompany � - FOR APPLICANi TO Fflt!N � �R�
�rtified copy is hereby furnished. New Residential Btdgs. Pool �H No. FEE
+�ertefied capy.is fifed with the co�nty bvitdir�g inspec- �&2-Family,Sq.P. s — S LdCALIT
tion department. � Multi-family Sq.Pt. NEARESf
xrpu'- Residential Swimming Pools CROSSST.
Dnte 7-2�–g�' Appticant M(�'��F.l�artryC owNER ort � �
� - .. FIRM NAME
-- � � CERTIFICATE QF EXEItAPRON FROM WORKERS' Outtets:Rec_Light_Sw._ - ��� �
� -COMPENSATION fNSURANCE - A�URESS Dr 2
(This sxtbn naad no}Iw eo�nplotod if iha wurk involved 6r Firef 20
Total No - Additiano! CITY • Tel.No.
tM pormif is foe on�Mxtdrad doller€(SiQOj or tefs.j - . .. . . PtAN CHECK � – � 41
. I cerrify that in ihe performance of ihe work for which this � APPI.tCqNT �
permit is issued,(shdll not empfoy any person in any manner - .
- so os to--become subjecr to the Workers'[ompensation Laws. Cfghifng Fixtwes First 2(}� ADDRESS
�- - � Totat No. Additional �
Dote � npplicont . CITY. _ . Tel.No. ,
� NOTtCE.TO�APPLICANT: ff, ofter making this Certificate of fixed Appliances Not Over 1 HP - pERM1T . . - ,,,
Exemption, you shou�d become subjed to the Workers' �Ra�9e_Heate�_D.W.— RPPLICANT a a����. �
. Compensofion previsions of the Labor Code,you must forth- Oven _Dryer _W.M.— qDDRESS� !
�� with.comptyr with such provisiorts or this permit shat) be roP _Fnu —w.y._ p'd• { �'2�'I
. deemed revoked. . - � Hood _Fan _Other_ ��TY TeL No.
� LtEERlSED COh#TRAE#QRS�EC#ARATIt3N� - p�sp. _Room Air Cond. — ��N ' CG
. €here6y of#irm thW f arrt fieensec}under provisions af Chapter 4 - REG.NUMBER
(mmmertcing.vr"rth Section 7Cq6)of 6ivisimr 3 of fhe Business DISTRICT N6. - PROCESSED BY
o�d Professions Code,and my ticense�is fn fu�tftsrcennd effert. � Power Apporatns&.Earqe Appliances .. - .--.__- -__–___._ . __ ... y
- $ize&7ype HP,KW,KVA,ar KVAR � � - (j
a
License Number��Q7Q� - Lic.Clas�'�,Q Up to 1 Irtd_ � fINAC � � - V-
.T��2�H5 Over i fo 10 Inct. DATE}�� `i�,–�..�_�.�- ALIDATIOH d
_ Contmdor '�-�1'Cr11 Date pver lOto�501nc1. � � 1–
� � . . PINAL - ._ �
. I am exempt under Sec.- � pver.50 to T06 Inc . ... . 8Y "'"^���" 6
- 6.8P.C.for this reawn - , Over 104 . ' y�
� �fe. . Seroices,Sw6d.,MCC 8 Panelboards - � �
� - � Q-2ClD Amp.Under dOQ Y-
- _ Signoture , 201-taW Amp.Under b00 V - - �
.❑ . Over 1000 AmP.or Over 6pQ V
Exemption far Reg.Maint Eled. 2.�.��7�
. SINGLE FAMILV Tem �PowerPole& -
p.- Apportenances
HOME OWNER-BUtLDER DECLARATION Sign wifh One Branth Cirtoit - �� � � � ��
i hereby affirm that I am exempTfrom the Contracfor's license Additionol Si n 8ranch Circoits
Law for the folfowing reason(Section 703L5, Business and . g � �� � � ;� • �(}'rJ.5(1
Professions Code�: �
� � � - Misc.Co�rduits&Condudors � � � •�• � C�5 Q c
I,as owner of fhe property,will do the work pnd tFe
strutture is oat intended or offered for saie(Secfion Other(See Complete Fee Schedulej_ � - Q.�_L�,_��_
7644,Bosiness and Professions Code}. -
- CONSTRUCTION LEND�NG AGENCY � - �- - .
I hereby affirm that there is a cansfruction lending agertty for . . � .
� the peFfofmance of the-work for which�ihis permit is issued �pERMIT�FEE (Sub-Total) � �
(Sec.3097,Civ.C.).
, PIAN CHfCKING FEE � _ - � '_ . . . � . .
Lender's Name - - � -
- � . . . PERMIT lSSUING FEE Q � _ .
Lendefs Address � - � -
I certify JhaY 1 have reod this applimfion and sfate that the T07AL fEE. - , . �
above infortnation is mrrect.t agree ro mmply wifh oI!Counly - � � - -
� ordinonces and State lows regulating Electrical wiri�g,and -
hereby outhwize.represantufives af ihis CouNy to entar upqn � � �� � -
ihe bove-mentioned properry for inspection purposes. SEE REVERSE FOR EXPEANATORY LANGUAGE
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