HomeMy WebLinkAbout1647A � - WQRKERS'CQMPEN5.4TION DKLARATION ��'� ���B1 APPLICATION FOR ELECTRICAL PERMIT ��� I
t hereby affirm thot I have a certificate of wnsent to self �E"60�G
inwre,o�o cert�ficate of Workers'Compensation Insuronce, COUNTY OP LOS ANGELES BUILDING AND SAFETY
- or a cedified"cnpy ihereof(Sec.380Q,1a6.C.j. - �
. p❑olicY f1o.C'7777tSI)SlY'pmppny �.. . �R APPLICANT TO FILL W-.-�. - �OB .Z�r-j- - . '�
riified co is hereb .fu�ni9hed. Fi1CH NO. PEE '���
pY Y New Residentiol Bldgs._ P, s �
Certifigd capy isfiied with the counry building inspea �g 2-Fomily,Sq.F
s _ f LOCALIT
� �� tion department � . .. Multi-family$q.Ft. CRO55 ST.-� - • .3 . . �.
Residential5wimmin Poafs
DateZ 72—RS APPlicant nreu �.��. ��TC 9 OWNEROR ' .
F��rn tiar� Anden
� CERAFlCA7E OF EXEMPTI�NFROM WORKERS' . p��{en;Rec_LigM_Sw._ -�'n -
- �� COMPENSAitON INSURANCE � � � � ADDRESS .
� (rn�:aediurt e..d noi 6.campletea iF kh...ork imoFr.a by . Firsf zo _ __
tha pQrmli 4�For o�w hundrod doflars{SI00)or I�ss.}� Total No. Additional CITY • � Tel.
- . PIP,N CHEQC
f certify fhat in rhe perform�snce of ihe work for wkich this � . . _ . . - APPL�fANT�
� permit 4s issued,I shafl not employ any parson i�any manner -
w as�ro become subjecl to the Workers'Compensation laws. Lighting Fixtores Pirst 2(t AQQRFCc
- - AddFtional
. Fotal No. . CITY � - Tel.No. . � ��
� � Dote � Atpticant - Fixed Apptiances Not Over 1 HP PERMIT - ��
N6TICE TO APPLICANT: If, after making tbis Certificate of � qPPlICANT n'jj° rx,'� F.C3�7C`PRSC - ''.
Exempt�on,- you shoukd 6ecome subject to the Wo�kers' Ronge_Heater_Q.W. _ � .
- Compensatiort praviseons of tfse Labor Cocfe,you must fortF- Oven —Dryer _W.M.— ADORESS ��.
� weth�compFp with such pravisions-or-this perreit shalt�be Top —FAU _.W,H.— � �
� deemed.revo&ed. - - - - Hood _Fan _Other_� CITY Tel.No. .
�� - � LlCENSED CONTRAGTORS DE€IARATkON � - i�EwS€OR --� -
�� there6yaffismtkwtkamlicenaeclu�der�provisiwisafGh�ter4 - Q`�- —RoomAirCond- — REG.-tattnk&fR ��.— . .
- - (commericing with�dion 1WQ}of Qivision 3 v#the 6usiness power Rpparatus 8 lmge Appliartces DISTRICT NO. / PR - BY � ;
and Prnfessians-Code,aadmylicense is in ful4 force arrd effec�. .- _ - � . � ' � � �
�� � - ' - Size&Sype HP,KW,KVA,or KYAR- . � �
Lirense Number 42(l?48 Lic.Class f`-��d Up Fo 1 Ind. FfNAI �� � ,
� Over 1 to lO lnd. DATE Q � � 6C
Confractar $'],��lf+�], Dote 7—�7—R�+ Atf�AnOFF 0
❑ . . Over 10 to 50 McL F�Np, '� � U ..
I am exempt under Sec Over 5Q to 100 Inc. BY � �
8.8P.C.fw this reason ��ef�� � Z .
, . � �ie_ Senites,Swbd.,MCC&Panel6ohrds � - - - - ^ ,
� 0-2W Amp.Under 600 V .. - . . .
� Signature ZOt-}000 Amp.Under 600 V - 2 1 6 Q.�A ;
� ❑ - - - Over 1006 AmP.or Over bOQ Y - '
Exemption for Reg.Maim.EIeU. -#�� �'*�2
_ SINGLE fAMILY Temp.Power Pole&-Appurtenances - .� • � d S�j a .
. - FfOME OWNER-BIFILDER DECtARAFIQN - Sign wilh One 8ranch Cirwit '
._ I hereby affirm that i nm exempt from the Contractor's license �- ,�� 1 Q�j,S��_,., '
Law for ihe following reason(Secfion 7031.5,Business artd � Add'aona4 Sign 8ranch Circuits -
� Frofessions Code}: - .. - . - - Q�f;`�,S,—$ -rj �,
� ❑ I,as owner of the ro rt will do the work and the Misc:�Condoits&Conductors � . � - '�
P � Y' Other(See Complete Fee SchedoleJ_
s�mcwre is not intended or offered for sale (Sedion _ . � � i
� 7044,8usiness ond Professions Code). .
�
��� CONSTRUCTION LENDWG AGENCY . . . . �
I hereby af4ivm ihm ihere is o conslruction-lendirg agency for -
the pehormance of the work for which ihis permit is issued PERMfT�FEE � (Sub-Totat} .
- (Sec 3097.Civ.C.).. . . .
- � � - PLAN CHECKING fEE -
� Lender's Name /f � �
� - . PERMf2 ISSULNG FEE.. ._. . _. _ v . � _ �
; Lender's Address � - �r � .
� I certify ihat f have read this applicofion and state that the . TOTAL FEE _ � . F��_�� .
. - above infwmotion is corred.I agree ro comply with ail County ,
ordinances and State laws regulaling Electriml wiring,and - -
hereby authorize represeMotiJes of this County to enter upon �
�h bove-mentioned property for inspection purposes. SEE REVERSE fOR fXPLANATORY LANGUAGE
� � �� �
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