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HomeMy WebLinkAbout1751A (10) �yORKERS'COMPF.NSATIONDECLARATION 76A663 APP�fCATI�N FOR ELECTRICAL PE�RMIT . �'i - rF-unFt�t�ani '. _____.'_'_' ' _' ' _" '_ ____ ' _ _ _ __ --- _ ____ __ ..- _ ____'___ � ` I hereby affirm that I have a certificate of consent to selF CDUNTY OF LOS ANGEIES BUILDING AND SAFETY � insure,or a certificate of Workers'Compensation insurance,or � . � � - � a eertified copy Ihereof(Sec.3800,Lab.C.) PolicyNo.J'L`��� Company `�t��'� '"p�P' �ZZ� FORAPPLICANTTOEACHNNO. FEE AODRESS ������ �• �"'a���'c�Y �'�-� { New Residential Bldgs.&Pools � � �❑ Certified copy is he[ebY rurnished. - 1&2-Family,Sq.Ft. � — $ LOCALITV ','.i;.�li . � - Multi-family Sq.Ft. — NEAREST � -� a � Ceriified capy is fifed.vrih[he coun �b,�ilding inapaction .r- CFtoSs ST t t t.., r._ � department. t Resideniial Swimming Pools OWNER OR ,�. . . � -�t.���'t� i�:5�. �J�F, � FIRM NAM£ !1t .�.��"= i;:` .,ni.'1.�. � � Date-3����3- A�plicant ' Ouilets:Rec._Light_S�a�. qDDREss � -�F �7 t, First 20 � � CERTIFICATE OP EXE�IPTI FROM WORKERS' Total No. Additional CITY - �.� Tel No. 5�f ^-'?]') � O�, � � COMPF.NSATION INSURANCh: �. PLAN CHECK .;� v�„�,.,z u � � {This section need not be completed if the work involved APPUCANT '-� � � by tlte permii is for one Iwndred dollazs {$1.00)or tess.) ��9hting Fixtures Pirst20 qoDREss�f.7"�.-.� .z:.z`.'� -3�.t���..�u � Additional ' � I certify that in the performance of the work fw which this F xed App�iances Not Over 1 HP CITY`f,, n� -:}^.,y �l?�tel No. {3;�,`,!-?�71� � permit is issued,I shall not employ any person in any manner PERMIT � so as to 6ecome subject}o the Workers'Compensation Laws. Range—Heater_�.W._ ( qPPLICANT 7 ��` - � � � Oven _�ryer_W.M._ � ADDRESS � � g Date� �Appticani Top _FAU _W.H..._ � � HOod_Fan _Other— CI7V � Tel No. ^ NOTICE TO AF'PLICRNT:It',after maki��g this Certifieate of Dis _Room Air Cond._ LiCENSE OR 2�,�-1�,7 _ � �,_ra y— � � p' REG.NUMBER ' Class � Exemption, you shouid become subject to the Workers' - Compcosation provisions oF thz I.abor E'ocle,you must fnrth- Aower Apparams&Large Appliances DISTRICT NO.� PROCESSED BY `� � i��iEh cnmply with such provisions or this permit shall be gi�e&Type HP,KW,KVA,or KVAR , ,� Y /'3�y'V� deemed revoked. fy � Up to 1 incl. FINAL i Over 7 to iD Incl. DATE f � f ry ._.,�% VALIDATION � LICENSED CONTRACTORS DECLARATION Over i Q to 50 Incl. a'"' � o � " - i herehy affirm that I am ticensed under provisior,s of Chapter Over 50 to 100 Inc. gY Al � 9 lwmmencing with Section 9000)of Divislon 3 of the Busi- Over 100 � v ��' i� ' ' � ness and Yrofessions.Code,nnd my ticense is in full force and - * � effect. Services ' � ����e { � License Num er ?a '�r,7 ,^,_c�� 0-200 Amp.Under 600 V , „ � �;C(i Lic.Class �„t-� _��,.;. ���a , t`ry r._7 2Q1-7000 AmP.Under600 V _ �z , � Con[ract � " �:tte � �r"` Oaer 1000 Amp.or Over 600 V . _ s " -�''= � ' II0�1E OWNEA-BUbDF.R DECLARATION Temp.Power Pole&Appurtenances -- -� � �r�? s I hereby aff'vm that I am exempt from thz Con[ractor's .Sign with Ooe BranCh CirCuit - �� �-# j License Law for the foilowing reason{Section 7031.5,Busi- Addiiional Sic�n Branch Circuits . . � � ness and Professions Code): � _ � � `�Misc.Conduits&Conductors � � � *� � �.I, xs owner of the property,will 10 ihe�wrk and the Other(See Complete Fee Schedule)— , _ structura is not intended or offered for sale (Section . � 7044,Businzss and Professions Code). - �� CONSTRUCTION LENPWG AGF:NCY - � � � . 1 hereby affirm that there is a cons[ruction lending aRency . � for the perfurmance of[he work for which this permit is ��� pERMIT FEE (Sub-Total) - � � . issued(Sec.3097,Gv.C.). � � � Lender's Name — � P+ � PLAN CHECKING FEE 40ne-Fourth Permii Fee} ; Lender's Address' � pERMIT ISSUING FEE . .i'J � � � I certify that !have read this application and state that the � TOTAL FEE ,�,� . _ � abnve information is correct I agree to com01Y with ali County . . - � o�dinancns und Sta{n laws regulating Electricat wiring, end � . � � hereby authorize iepresentatives of this CountY to enter upun � . � ,,�: I the above-mentioned property for inspection purpoxes. . 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