HomeMy WebLinkAbout1652A - . WORKERS COMPENSATION DECLARATION �� �o�e� ARPLICATlQN FQR ELECT�ICAL PERMfT �
1 hereby afflrm fhnt! have a tertificate of consent to salf �"B� . �
insure,or a cectifimte of Workers'Compensation Insura�ce, COUN7Y OP LOS ANGELES BUILDIAfG AND SAPETY
or a certified copy thereof(Sec.3800,tab.C.) _
' PDol�ity No. �'7�77dn�fS�mponY � . FO�APPLICANt fQ FILC W. . -lOB '
Cntified copy is hereby fumished�. New Residential Bldgs.�� EAq�[ NO. FEE M6RES5 423- �x13S D �
Cerfifiect ropy is filed_wi�h ihe county build�ng inspec- �g 2-Family,Sq. � — E ����
- - n tion departmeN. � Multi-fomily Sq.Ft. — � �NEAREST
�F �e � Residentio4 Swimming Pools � GROSS SL �
P«te 7—�2—$5 Applicont OWNER OR
FtRM PIAME
- � � CERTIFICATE OF EXEMPTION FROM WORKERS' � � - /wtp,2� , -
OuNets:Rec_lighl_Sw._
- GOMPENSATION INSURANCE -� �� - � - /oo2Ess
(Tkfssoctbw nwd not be cwnpl�t�d-N tM-wur4 tnrolwd br First 20
tho pvrmif is for ono hundr�d doltors(�I00)er I�ss.)..- Total No. - �q�difroriol GITY ' Tel � �
- PkAN CHECK . .
1 certiEy thot in the performance of the rvork for which this - - APfq.ICANT �
_ permit is issued,I shal!not employ ony person in any manner � .
. so as to 6ecome suhject to the Workers'Compensatioalaws. li9hting Fiatures First 2(Y ADORE55 . -
- � - � � ' � Total No. Additionaf -
. .�pate a.rPlicoN - � . .- CfTy Tel.No.
NOTICE TO APPLICANL If, after makin this Certificate of Fixed App4iances Not Over 1 HP . PERMIT - - �
Exemptton, ynu shpoifd �become-su6jed to the Workers Ronge_Heater��D.W. _ ��'M� n
Compensation prodrsions-of�the ta6or�£ode�,��yoa�must-forth- Oven _pryer _W.M.— - ADD&ESS p�o. � l�ll
� with comply wilh such prorisions or ihis�permit sholl be . Top _FAU —W.H.— �
deemed revoked. . - - - C4tY� .- - --� Tek.Na.
- � -.LICENSEQ CON7&ACIQRS.DECtARATIOAI---_-_ Hood _fan _pther_ _
- Disp. _Room Air Cond. — l��E� Class.
� "-{he�eby affirm fhaf I�om li[ensed under provisions of Chapter 4 . ttEG.NUMBER _
� . (cpmmencir�g wFth$ectiQn�7Qpf}J o#DivisiQn 3 n€�he 6usiness pQwar Apparatus&Earge Appliances DISTRECT NQ. PROCESSED BY
���_andProfeuiortsCode.sr+�.mylicerxse-isinfu!}fvrceand:eHec�. - >'
- ` - � Size&Type NP,KW,KVA,ur KYAR �'
- License Number �QZOT�S� Lic C4assfi-1(1 - � Up�to 1 lncL. FINAI - . - V
.. . . Over 7 to IO lncl. �A� �1 ' �`.
� Contractor Rl�j-rj„{-a,l Dote 7�?�-R4 � - YAl16ATIQN 0
QOver 10 to 50 IncL FtNAt �j
I am exempt-under Sec pver 56 to 100 Irsc BY �,y
- � B.&P.C.for this reoson � Over 100 . a'
. ��e. � . Servlces,-Sw6d:,MCC&�Ponetboards � � -
�
� . Q-2W Amp.Under 60S}V
. Signoture � 2(11-IOQO Amp.Under 600 V -� .
� Over kODO kmp.o�Over 600 V �}6 5.2 A
ExempFion for Reg.Maint.Efect. �. •• . .2
SINGLE fAMILY Temp.Power-Pole 8 Appurtenances �
HOME OWNER-BUILDER OECLARATION Sign with Qne Bronch Cirwit - , � • � �,�,�,rj�
I hereby affirm tFwi I am exempt from the Contrado`'s License Add���onaG SgR&ancb Circuih -
- Law.for the fo4[owtng reason(Section 7Q31_5, 8usiness and - � � ��-���O�
Profsssions Code�: _ � � -
❑ �,as owner of the prvperty,will do the wark and the Misa Candu�fs-8 Coodudors - Q�,�S�8 Jr -
. structure is not intended or offered for sole (Section Other(See Complete Fee Schedule)— � � �
7044,Business and Professions Code). � -� -_
� CONSTRUCTION LENDING AGENCY .
�. �hereby affirm thai there is a construction fending agency for
the pefformance of tha work for which ihis permit is issued - PERMiT FEE (S�b-Totol) -
(Sec.3697,Civ.C.). . . �
� . � PL4N CHECKtNG FEf - �
lender's-Name �
� - . . . PERMIT IS51lING FEE_ � -
� Lender's Addreu ��-y� . . . . .
� 1 certify that-1 hove read this application and state that ihe TOTAL fEE ,(J
abuva informotian is corcetl.t agree to tomply wNh afl County , � � .
�- ordioances and Slote faws regulating Eladrical wiring,and ..
hereby avthorize representatives of this County to enter opo� � -� . � �
the bave-ment�io�nJed pmperry for inspection purposes. SEE REVERSE POR EXPLANATORY LANGUAGE
. Sign�Permittee!������� - � �� - . . - . ii
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