HomeMy WebLinkAbout1669A WORKERS'COMPENSATION DECLARATION ���3 ���B1� APPLICATl4N FOR ElfCTRICAl� PERM#T � ,
� I here6y aHirm that.!have a certifiwte of consent ta se4f �'�' -
insvre,oi a certlficate of Workers'Compensat�on Insorance, COUNTY dF LOS ANGELES BUIIDING AND SAFETY _
w Q certified copy thereof(Sec.�3800,Lab.�G.) - - � . � �
., Poli[y No�.�QrjQCompany ;�)� _ FOR APPLKAHT TO fltt IN ._ JOB -� -
���,❑ Cartified copy is here6y furnished... . . . New Residentia4 Bldgs. Is .�'� �-. :- _�F,E.._-.- �RE . .
� g_.-. _ y COCAL � .-� -
, �Gertified-copy is fited�with ihe county burldirig��ir+'spec- - -t&2-Fam�ly,Sq.F
� tion deporfrnent. - - ---"- - - . Multi-family Sq.ft . �— �NEAREST -.
. :. - CROS4 5T.
Date�7-�--A� Applicunt��,2'„N �'�`F �.�'�T(j Residential Swimming Pools OWNER OR - . _
€IRM W
� CERTIFlCATf OF EXEktPFFON fRUM WORIffRS'� Quflets:Rec_Light_Sw._ - � ����
- � - - COMPENSATIQN INSURANCE - � -�a�oREu '
(This sactioe nwd aot 6�eomplWad if 7!w wesk ie�ol�rod by � First 20 . CIN .. . T
� fhe'permtt b fer onelwndrei#dollars�STlig)ar(e�s�-- Towl No Additionol . � . = -
. . _ _ PLaFt GHECK �
-� 1�certify ibqt io the performance of�he wo�k for which this . . . qpp«p� - - �
. _ permit is issued,I shall not emptoy any person�in any manner � -
so-os ro betome sub(ect to t6e Workers Compensatiort taws. Lighting FixNres Firsf 20 � AADRESS
� -- - Tatoi No. additional � GITY . - - Tel.No. �
- Dofe � .4T.plimnt � Pixed Appl4ances Not Qver t HP . PERM4T —�-
� NOTICE TO APPtICANT: if,after making rhis Certifimte of qpp���T ��in �+(� F!(,�+{2T(,+
� E.empeioa, you sbouW become subjecK �n �he Workers' Ro^9�---.Heafer_Q.W._
Compenwti¢n�rcavisiorts of tFic Eebar-�ede;-pou-must��orfh- Rven ,Dryer —W.M.— ADDRF55 - _
�� with�compfy-witf�soch�prnvisions or�this�parmH�shal) be . _fop �„FAU -_W.H.._..._ _
. deernadrevoked.�- - � - - Hood ,._Fan _Other_ CITY � . - Tel.N �
' �- i1C€NSEO CONTRAETORS DEfGiRATIQN uCEtaSE Oa -
� therebpaffi*mthotYdmlicensed�urtderprorisionsofChapter9 �.6isp:�—.Room-AirCond. — REG:NUMaEa G�°u� �
�. (cammeruirtg�.wiN,Section�70�6juE.D;viseon3of-�s�Bnsiness - QI57RICTNp. PROCESSEDBY �
. .a�rc!ProEessiomCodt,��o�dmylicenx is in fvkk forc�artd'effect. Power Apparotus&Large Apptiances . . _ �
�rc
.- � . - - � � -Size&Fype HP,KW,KVA,or KVAR - - � O
. - License Number .. �17Q7AR Lic Ctass �=�'1 n � Up to 1 Irrcl. � fINAE � - � V
Contractor N.l a1�1'T-i[��-�. : . ']-22-$rj . .Qver}ta 10 Incl.. �A�E _�.�-�'r� YRUDRTION Q
. Date . Over IQ fo 50 tncf. �
❑ Ft V �
. . !am e�cempt under Sec. - � 4ver 5Q to IOQ Inc. HY 6
� B.&P.C.tor this reasan � � Qver 1Q0 . : � ` H
-:. --... . - - Se�aices,Sw6d.,MCC&Panelboards - � . .. � �
Date: . 6-204 Amp.Under 60Q V � � � � -
, _ Sigoroture . ...�l-10�0 Amp.Under 600 V � . . ��6�9�
❑ - - Over t00Q Amp.or Over 5Qp V - . �
Exempiion for RBg.MainL Elect. - �� � � � �'�'
- SItJGL€fAMiLY � Temp.�Power�Pole�BAppurlenaw€es--
HOME tJWNER-BUILDER-DECiARAfION ;�-• � O��O -
� Sigo with One&anch Clrcuit . . , �.
. I hereby aHirm that 1 am eaempt from the Contrador's license �. qdd��tonak Siga Broncfi-Circuih---�-� . . ��a .c u"��.s
Law for the foUowing reason(Section 703t,5,Business and 1 V w u J u
, Professian:Code): - � . - � 0
, � . � � - Misc Conduits&Conductors � �_ �7 2 Jr-t3 5 �
I,as owner of tbe property,witl do the work ond Fhe
� �sfroctore is not intertded or offered for sale(Sedion � �her(See Compiete Fee Sthedule}_ �
7Q44,Business and Rrofessions Coda). _ .
� CANSTRUCTiON IEN�ING AGEEJCY � �
: - 1 hereby affirm fhat there is a tonstruction lending pgency for -
the performance of the work for which this permit is issued � PERMIT�FEE� �� - (Sa6-Tota7)
, (Sec.3097,Civ.C.). � .
� � �. PLAN GHECKING-.lEF - . . .
-�. Lender's Name - --
- - - PERMIT tSSU1NG FEE - - � - � .
� Lender's Address . . . ��rD
� 1 certify that I have read this application and state that the TOTAL FEE . . i,.�
abova information is mrrect.1 agree to comply wirh all County � - �- .
ordinances and Sfate laws reguloting Electrical wiring, nnd .. � �
� bereby aoikorize fepresentafives�of this County to ertter upan -
� the ove-meniioned property for inspection porposes. �
✓J SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signature of�ermil�ee �-�t� � .
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