HomeMy WebLinkAbout1648A WORKERS'COMPENSATtON D€CtARATION 1bn663 �a�e�- p�PPLICATIQN FOR ELECTRICAL PERMtT �
� 1 hereby affirm thut-F have a tertificate�of consent to self -CE-8o6G
cnsure,or q cert�ficate of Workars'_Compensotion Insurance, COUNTY QF l05 ANGFLES . BUILDING AND SAFETY
� or a certified�copy thereof�(Sec.3BOQ,Lab.C.} -
Policy t3o._'�.�.a�ntparty. �. � . fOR APPIICANT TO Rll��l J08 � .
� � ertified�co -is here6 fumished . � E4CN NO. fEE� ��'� �35 � -
py� y . New Reaidential Bldgs. P ol ,
1&2-FomN f --- E LOCALI
�Certified�copy is filed with tha tovnty 6uilding inspec- Y�S4� _
. -�tion departmeot. . � MuUi-family Sq.Pt. NFnRESt � ,�J �
x N Residentiol Swimming PoolS CRO55 ST. pGY�J �,
� Date.7-22�$S. _ qpplicant .�' 1��.�j'��'' . OWNERflR . .
. . . . FIRM NAME
� C€RfIfICRTE CF EXEMPFI6N FROAA WORKERS` Outlets:Rec_Light_Sw.T ��`�� - � �
.� - COMPENSATION-IAISURANC€- � a�E
� First 20 - .
(Th[s�aspoa awd-wet b�cote�t�d if ti�work iqvo7rQd bY - � � GITY • - F �
the permN is for orw A�ndred dollars(5106j or bst:) Taof No. Additiona[
� �f.certiPy tfiat i�the performance of the work tor which this _ , . qppNj��IX
permit is�issuedr 1 shaH not emp4oy any person in ony ma�ner - - .
. w os to bacome wb{ect to the Workers:Campensation Laws. lighting Fiztures First 2(1 AD�RE55
� ' . - Tata!No. - AddiHorwl . . .
. CITV Tet.No.
, Da1e � App���a�t � - � - fixed Rppliances Not 6ver 1 HP � p�M�� - � �
NOTIGE TO APPL4UNT: If, nfter making tbis Certifimte of ' - APPLICANF n x -
- Exempt(on, you should become sobject to fhe Workers' Ronge_Heater_D.W._ -
� Cpmpansation provisions of-the Lo6or Code,yo�-must tpnh-� Oven _Dryer —W.M.— - AD6RE55 � �
with comply with such provisiony or fhis permit shall be Tap _FAU _W.H.— - -
: deemed revoked._ . . �d �Pan _Qther_ � GTY •� Tek.Na. - .
___ - .__.. —
� - . LICENSED CC}NTRACIDRS E?ECLARAIJOAI -.. ... t�CENSE Ott -
. t here6y affxm lhat.l sm licsnaesi ufu��9rQv�sinnsof-Chapfer 9 �Qisp. _Room Air Cand, — REG.NUMeER Class _ .
(commencirg with Sectron 7000}of€Avisia+3 of 4he�6usxvess - DlSTRICE NO.. �- PROCESSE6 BY �
andPrafessiowsLode,andeny-ldcanselsic�full�aice.qnd.effeci.. .- Power Apparotus&Large Appliances . . . . . . �
. Size 8 7ype HP,KW,KVA,or KVAR � Q
iicense Number� ���IaR Lic.Class - ��� . . . � FINAt � U
. . . Up ta 1 Ind.
'Ft1F+1tf'ri[�1 ?-22—$5 , Over t to tQlncL �TE . � � �� YAUDATION Q
-Confmctor- �re , � Over 10 to 561nd. - �
FtNAL � ~
4, I am exempt under Sec. - _ . �ver 50 ta 100 Inc. 8Y _ �
B.BP.C.for this�eoson Over 100 . vl
- Service:,Swbd.,MCC 8 Paneiboards � � � - ?
oare: o-zoa,4rr�R.under boo v � �1 6 4�8 A
. � . Signature -- 201-1 WQ Amp.Under 50�Y � � � �
.. ❑ . - .-Orer 1000 Amp.or Over 600 V - _#��� ��� •�
Exemprio�fw Reg.Maiat.Elect.
�1 • 1D�50
SINGLE FAM4CY Temp.Power Pole 8 Appurtenances -
- HOME OWNER-BUILDER DECLARATION - - - ,��s 5
�� 1 hereby affirm ihai I am exempt from khe Co�troctor's License 5�9n with One Bra�th Cirroit - . � O V.�Q cz�-
- Law for the-foltowing reoson(Sectivn 7031.5, Business and - ���tioewl�S'rgrt&ortch Circuris - . . . II 7 2 G_��� _
�
- Professions Code�: � -
� ❑ 1,os owner of the property,will do the work and the Misc.Candoits&Conductors - �- -
. struUure is not iniended or offered for saie (Section Other(See Complete Pee Schedule)— � �
7044,Busi�ess and Professions Code).
-.. CONSTRUCTION LENDING AGENCY - _
, 1 hereby affirm-that there is a consVuction Iending agency for - .
_ the performance of�he work for which this permit is issued PERMIT FEE � � . (Su6-To�ai)
. (Sea 3697,Civ.C.). � .
_ - � . _ PLAN CHECKWG FEE . �
- Lender's Name - -
.. PERMIT ISSUING FEE ,
'_ - Lender's Address . .
I certify that f fiave read this application and stare thm the TOTAt FE€ -
above information is cwred.I ogree to romply with oll County � -
� ordinances and Sta�e lows regufating Electriml wiring,6nd , � - �
hereby authorize represenlatives of�his County to enter upon .
the obove-mensioned pwperty for inspection purposes. - -
�� , /� �` ._ SEE REVERSE POR EXPLANATORY LANGUAGE
a� ���1 C.
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