HomeMy WebLinkAbout1663A WORKERSCOMPENSATIONOEGCARATION � �d� ���81 �pplIC�TI4ld FOR ELECTRICe4L PERMIT � �
� I hereby affirm that 1 hove a certificate of consent to self �-�
insure,w a certificate vf Workers'Compenmtion lnsurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
- or a certified copy thereof(Sec.3800,tob.C.} �
� : PQoticY N°�'�gComponY�� ._ . .-- .. . - FOR A►YUCANT TO Htl MF�� � .
erFified copy is hereby furnished. . � . � New Reside�tiat Bldgs Iy�•� �`� NO. FEE AD��
� �ert�fied cQpy is filed wifh the co�nty boilding inspec- 1&2-Family,Sq.F. c7 S — S LbCALI •
fion depa/tment � Multi-famify Sq.Ft — NEARFST
�� ��r Residenfiol5w�mming Pools OwNEROR. �� �
Date�7—?�—$�j.- Appticgn€ ..T .�.MrC'.,�t?-F'Lpr.fr. .
. FIRM NAME �
� �� CERTIFlCATE OE EXEMPTION.FROM WORKERS'- . � -- . -MAfL �
- - COMPENSATfON INSURANCE - Oullets:Rec_light_Sw._ - App��� .Q 1f P�']t-�-V� D.L' ZQZ
h4 sacflon nasd mr#6e so let�d if The vyark invuFred b Firsr 20
� R � � Y Tatal No. CITY . � Tel.No �
. tkr parmit is ior aw:hundrad do{iars(3t�)or bsa.�-- .. Addittonal _. ... — — �
PLAM1I
t-cer)ify_thai in�the�performance of the�woTk--farwhich this � qpR�pry�. _
permit is issued,-I sha41 no!employ 4ny person in pny mpnner - --- -
so as to 6ecome su6jeci to the Woikers`-Compansalion Laws. Eighting Fixtures First 20. A6RRES5
�-- � � ' . Tota4 No. �4dditionol CITY . - Tel.Na.
. Dnte � arplimnt � Fixed Appliances Nof Over 1 HR pE{�µR .
NdTtCE TO APPLICANT: If, after making this Certificate of � _ qppii�qtiT rF p �+�po }�,+�pr.t •
- Exemption, you should become sobject to the Workers' Range_Heater.�Q.W__ --
� Compensatian prov[siaen.af�:the Laber.�Code.-yQu�musF�fQrth- Oven _Dryer _W.M._ ADDR�`5�_ ._
with compty.with such-provisions-or this permit��shal! be Top �FAU _W.H.— �""�'—� .
: deemecf revaked. � : �. - � - Hood _Pan _Other— CITY • - Tel.hEo _
� � tICEM1iSED CONTRACTORS DECLARATION -. � CtCEoISE OR �
� 1�hereby aff'trm thae t am licensed o�uler provisions-@t.Ghapler 4 Disp. _Room Air Eond. — �:��Mg�� . - Llau. �„
�� (wmmencing with-Sectiort 7000}nf Division�3 bf the Business power�Apporpfus 8 iarge Applinnces DISTRtCi NO. F PROC€SSEQ BY
- _arid P�ofess;sns CQds,o.rsl my IKense ts�n futt.fwce o�xle4Fecr. . / . . Y �.
� �
�. . . � Size&Type HP,KW,-KVA,or KVAR , � Q
'. . LiCense Num6et�2QTdR Lic.Class�—�(j � � Up to 1 IncL . ��I�Q� - -- �
e
' . . . O�er}to 101nc1. EMTE OC
� Contractoi�l�J=riral pote ?-22—SS �...'`�"��3� �_ VAl AT40N . (j
❑_ Over 10 to 50 lnd. FlNAt ~
1 nm exempt under Sec. Over 5Q to lOp Ino BY W�
B.�P.C.for this reason _ Over tOQ � `�` . . Z
�Qr� - Servlces,Swbd.,MCC 8 Panelboards - � . � �
� 6-200 Amp.Under G0p V ::�
' Signa�ure � - 201-t000 Amp.Under 60D V �7 ��3 R
- � . . Over 1006 Amp.or Over 60Q V . . i�
Exemption fo�Reg.Maint.Eled. #r � � + !� �
� - $fNGIE FAMILY � . .- 7emp:-Power Pole-&Appurierwnces �f • � �µ�j Q �
HOME OWNER-BUILDER DECLARATION - Sign with One Branch Cirw"rt
. I hereby affirm that t am exempt from the Contracror's license . . �p,�dltional�5igrr8ranch Girtoits� _ •'`� C��5��
�- Law for ihe fellowing reoson(Sec(ron 7031.5, Business and - � s
� Professfans Code}: � Q'],'��—�5 �
.. ❑ 1,os awner of the property,will do the work and Ihe � �'u'eonduits 8 Conductors � - ��
� structure is not intended or offered for sale(Section 41her(See Complete Fee Schedule)_ � .
� . 7044,Business and Professions Code).
� CON57RUCTION L€NDING AGENCY - --� - �
� 1 hereby aHirm that there is a construttion Iending agency for � ,-
- the performonce of the work for which tbis permi�is issued - PERMIT FEE` (Sub-Total) �� - - �
(Sec.3047,Civ.C.). �� � -
-- � �PtAN�CHECKING FEE - - -
. Leoder's Name D - �
� PERMIT ISSUING FfE � -
lender's Address � � . �
I certify thot I have read ihis opplicatioq and state that the TOTAL FEE .
above iniormotion is correcL I ogree to mmply wiih a14 County . �
ordirances and State Iaws regulati�g Eledricot wiring,and . .
hereby ao�horize representatives of this County to enter upon -� - -
. the ove-mentioned property for i�spection purposes. � � � . ,
1���tY. !!�.�Q�[� rS� SEE REYERSE FOR fXPLANATORY LANGUAGE
. Signmure of Permittee . Dote �. . . � J
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