HomeMy WebLinkAbout1658A �WOKKERS'COMPENSATlONOECLARATION -�d� �0�81- APPlICATIQN FOR ELECTRICAL PERMlT �
I hereby affirm that�have a cerfi#icate of consent fo:elf �'� � .
insure,or a certifimre of Workeri Compensation Insuronce, COUNTY OF LOS ANGELES BUILQ�NG ANR SAFETY
or a certified copy thereof�(See,3800,-tab.C.) . - �
� Policy No.��Q��ompany �jj�, iOR wvvuCANi TO-FlI.t Ml � J68 ....- .
, � erti#ied copy is hereby#urnished. New Residenhal Bldgs. �P9.,�I_s,_�,�� �-EACH N0. �-�- FEE�--_
ADDRESS __. • . �_-.
Eocaur
�ertified copy is#iVed witf�the�counly bvrfd'rng inspec- 1 6 2-Family,Sq.F���31� ; _ s - 26
�\tton department,' - M�Iti-familY Sq-Ft. C O55 ST.�
Date�—�'x—���TAppika����`�'N M�'�' F'�'TY'�PRT(�' Residential5wimmingPoofs ��a�
- - FIRM NAh0.E TI1C
�- -CERTtFICATE OF EXEMPifONFROM W4RKER5'-- � Outfets:Rec_Light_Sw._ � ��� � �
- COMPENSATION INSUR.4NCE a�R�
First 2Q
(Thts sentbn n4od not ba complQtad IF the work Fnrolvad by Totpl No. Additionat CITY � Fet.N
tl»permit Is for o�ro hundrad doNan.(SI00)u laas.} . � — '
I certify,fka4 in tFe�ps�rformance of the work for which this . � p�j�qM�
permit is issued,7 shcrtl nat emPby-anq penorrin any manner - � �
� so as ro become autijecf fo the Woit�ers'�Compensation�Caws. Ltghting Fi�€tures� . First 2Q ApDRfSS-
- - � � - � �-Total No. -Addirianol
a�Yicant - CITY - . Tel.No. � .
Dare , . . . � Ran e p Heafer_D.W.� APPE'IClWT T„_ a„C, �,'�e I
NQTICE SO APPEICANi:=![,.:.aEter-making-�tbis�Eertificate-o#� u x
Fiaed A lionces Not Over t HP ,
FacempiFon, you�shauld-becortra-subject to�ibe��Workers' - 9
. Compenwfion provizions of Ihe Labor Code,you must forth- Oeen�_Dtyer _W.M.— ADDRESS ��
weth comply with such provisions or ihis permit shall be Top —FAU —W.H.—
� deemedrevoked:_.. , _.�_. . _.. .._ .. -_:--.... __. . ._.___. . - CIFY . TBLNo.
� - . � LICENS€0 CONTRACTDRS QECLARAitQRI .- Haod �fon _Clther_ � —
Disp. �Room Air Cond. _ ���� - �Cka
E hersby a€Firm ihvt t nM Iic2n5ed uruler pravFsion3-af Chopter 9 REG.Nl1M8ER �,'—ZQ
(commonting.weth Secuon�7Qp6}a€ESivision�3 af tFe Bustness��, - , - DfSTRICT NO. PROCESSE�BY
. and Professions�ode,-w�d rtry license is fn fuH force and effxt. Power Appo�otus&targe App4iances . !� >
- . Size 8 Type HP,KW.KVA,or KYAR� � 1 Q
� �License Number G?().�IdR u�.cio:d'--10 � uP�o i i�d. - . - _ FiNat - .. v
. pver 7 ro 10 Incl. DAT€ p � � - - m
Controdar F.lP�`f�7G� Date 7"22—�5 ��`tC"?"��+J�-s-. . YALIDAFION . Q
Q .. .. Qver 10 So 56 IncL V �
ftNAi
I am exampt uader5ec � . Qrer 50 to 100 i�c. � 8Y � - �
� B.&P.C.foF thfs reason Over 100 y
- - Services,Swbd.,MCC&Panelboards � � - ?
- - �0�� 0-200 Rmp.Under 600 V . �
� Signotuee 201-tOQ6 Amp.Under 600 V . z 1 6 5 8 A
� . Over 1000 AmP.or Over 600 V � - �� �s • •'2
Exemption for Reg.Maint.Elect.
- SINGtE FAMILV � Femp.Power Pole&Appurtertances . �,� •1 Q 5 5 p
HOME OWNER-BUILDER DECLARATION � $�gn with 6ne Bronch Circuii . ��_
I here6y affirm that I am exempt from the Contractor's License p�itional Sign Branch Circuits ��' � G�"�"
Law for the foliowing reoson(Section 7031.5,Bu3iness and
- Profeuiom Code): - ���2�z£S J�
❑ - --� - . _. . .
I,as owner of the property,witl do ihe work and the Misc Conduirs 8 Conducrors -� -�- �-
st�ucWre is not imended or offered for soie(Secfion Other($ee Complete Fee Schedule)_ �
7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCV . . - � ..
I hereby affirm thot there is a construction lending oge�cy for . -
- ihe performance of the work for which this permii is issued � PERMIT FEE �� (Sub-Totalf
(Sec.3097,Civ.C}. .. .
� PLHN CHECKING FEE � � - .
lender's Name �
PERMlF-ISSU4NG PEE - � �- � .
Lender's Addreu - �
- t certify ihat�i have read this-epplimtion and state rhat�he TOTAL FEE . � -
above informetan is cwrect.1 agree to complp w'rih ai!Counfy ; .
. ordinpntes and Sttzte lows regulating�Hectricoi wiring,and _ _ . . . . �
hereby authorize represertfotires of ihis Covniy to enler upon � - �
�he bove-mentioned proper for inspection porposes. $Ep REYERSE POQ EXPLANATORY LANGUAGE
�LvIY'q�-! ������_�__�__ . E
Signature of Permiltee Date . � � E
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