HomeMy WebLinkAbout1688A (10) WORKERS'COMPENSATtON DECLARAiION �� ���$� APPtICATIQN FOR ELECTRICAL PERMtT �
� I hereby offirm tfiat I have n certificate of consent to self CEAU6G _ _ .
tnwre,or a certificate af Workers:Compenwtion lnsuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY
arn certifiedcop'irhereof(Sec.3800,Lab. .n) � � �
Pol .��.'� `��Compony ��/J. � FON APPLKANF SO Fltt IN JOB - � �
• Lj GaplifiBd Copy i5 hgr¢4y#umish�d. New Residentiol Bldgs.8 Po EkCH NQ. FEE '��
" ���/// 1&2-Fomil Ft. g — f IOCA�ITY - •
�y ��Cgrtified capy is fited with ihe county building-in5pec-. Y.59� _ � -
tiort deporlmerti. ��.. ` . . �Multi-family-Sq.Ft. ��ST. ��,. �3ysl
{ f ��[L� Residantial Swiinming Pools -•,!�
- Da�e--�!�APPlitanl (Tl r ._._ OVYNEROR
. � F4RM NAME�- �TI[.`
. � CERTIFICATE OF EXEMPTION fROM WORKERS' Ouilets:Rec_Light_Sw._ �` - �« - -
� COMPENSATION INSURANCE - AODRE55�Q I4 P3T'IC V1E�4J DY' 241
(Thta r4ctbn noad mt beaompleeed iF the wortc Mro4ved 6Y Firsr 20
- Nw parmit is for oea bundrod dol{on jS100}w tass.j - � Total Na. Additional CIN • Tel.No. - - 41
i ceriify thaf in Fhe perfwmance of the work for which ihis qp�p��qH�
" permif is issued,I shall not employ any person in any manner �
so as to become subject to the Workers'Compensofion taws. t�9hting P'rxtures � First 2� _ ADDRESS
- � � Total Na. �Additional CITY� � Tel.No.
�, Date - � �TAEK�� � Fiaed Appiiancea Not pver}HP� 7ERMii �� - -
. NpTtCE�TO-APPCICRNT-:-(f;-ofiter makin9-ffiis-Certificn#e-of urF.n r•., - ��G.
� E:emptian, yoo-shovfd-become-sobjact�ro�the��Workers" R¢nge_Heoter.�D.W.— APPLfCANT
Compenxifion provisimu-af-ehe-Lvba£ode;�you-mvaF�c�rlh- Oven _pryer —W.M.� ADDRESS �
with [omplp wifh such provisions or lhis permiF shp{I be .jQp, _FAU -_..._W.H.— �
deemed ievoked. � -� - � Hpocl _Fan _Other_ - � ClTY ��a Tet.No.c�g1-6461 �
� � tFCEN5E6 CQNFRACTORS 6ECLARATION tICEP15E OR- -
. IherebyaffirmlFwtfamkictnsed�underprorisictns-of�CFqpfer9 -.-:Qisp-._RoamAirCond. — REG.NUMBER. - . �Ip�. ."1�. .
(corcrmencirg with 5ecaon-700Q�.of Diruiaa_3..af..ihe.8usiness. � � - . DISFRICf P10�. � PROCESSED BY �
, Qrrd Prafessiar6s Gode,.cnd.my:license K in f�ll force ar�effect Fower Apparat�s 8 lorge Appliancas } '
- - � �j� /� ()p' /i - Size 8 Type HP,KW,KVA,or KYAR . , Q d
License Nomber_lZc2v?`�$ �- Lic CFoss� - Up 10 1 IncL FINAL . v �
Controdor��f r'-/?S�Date - . . Over f to 10 End. €}ATE`���_+�yl VAUDATtON O
❑ � Over f010 50 tncf. F�N� ►' 1
I am exempt under Sec. 6ver 50 io 100 fnc 8Y �
. 8.8P.C.for-this reason � 6ver 106 ► �� b�8 A ? I
� � Dafe: Services,Swbd.,RACC&Ponelboards �
- 0-2W Amp.Under 60Q V . 3
� Signature � �YQt.t00a Amp.Under 66Q V . . #� i o a •�
._ ❑ . � . .... - Over 7f10�AmP.or Over 600 V . j-s s E,�'� �
- Exempfion for Reg.Moint.E�ect.
�� SINGLE FAMILY Femp.Pawer.Pele&App�rtenances . •.s'��i ��c:
- HOME OWNEIt-BUItDER DECLARATION Sign wifh 6ne�Bronth Circuit
I hereby offifm thpt I om exempt from the Contractor's license . pdd�tierrat$fgn$ronth Circnits- - - - O�I.2 S"'�}�j
'. Low for the foliowirtg reason (Sedion 7031.5, Busines¢and � . . - - - �
Professio�s Codef: � - � . -
❑ 1,ps owner of ihe property,will do the work and ihe Misc.Conduits 8 Condutiws � -
�. slructure is not intended or o$ered for saie(Section - Other(See Complete Fee Schedule)_ �
- 7044,Business and Profsssions Code). �
CONSFRUCTION LENDING AGENCY - -�----� --- �
� 4 hereby affirm that there is a.construction lending ogency for . �
� the perfo�mance of the work for which this permit is iss�ed PERMIT FEE� . _ (S�b-Total) . �
(Sec.3647,Civ.C.). � - � , -
. � - PLAN CkECKIt+iG FEE � �
lender's Nome - �
� - PERMlT lSSIIING FEE � � . .. � .
. Lender's Address - -
. i certify ihnt I have reod this application ond state ihaf the TOTAL PEE� - �
- above information is mrrect.I agree to comply with oll Coonly � . - � -- �
� ordinances and State laws regulating Eledriml wiring,and . � , �
� . hereby oothwize representa�ives of this County to enter upon � � � -
the above-meroioned property foF inspection purposes. -$p�EYERSE fflR EXPLANfAT�RY LANfiUAGE
�,��1]� r�°?�`.a�.�_�-`� 8S` ----
_ rSignature of PermiHee . Oote .. . . �
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