HomeMy WebLinkAbout1074A WORKERS'COMPENSATIONDECIARATION 76A663 ,o,a, APPLICATION FOR ELECTRICAL PERMIT r����}�
I hereby affirm thal I hove a terfifita�e af consent to self �E'�
insure,or a certifcco�e of Workers'Compensotion Insurance, COUNTY OF l05 ANGELES BUILDING AND SA ETY
or a certified cop ihe�eof 5 c.3800,Lpb.C,) .
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P❑p�ity No. Com any . FOR APHICAM TO Nll IN � DD2E55 �
Certified copy is hereby furnished. New Residenlial Bldgs.8 P s EACH NO. FEE
� 1 8 2.Famil FL E = E LOCALIlY
Certified copy is filed with ihe county building inspec• Y.59�
tion depor�mem. M�t�i•fomily Sq.Ft. NEnREsr
CRO55 ST,
S�0� � � Residamipl Swimming Pools OWNER OR
Dote 1'��J-�Applicontc �
FIFM NAME
CERTIFICATE OF EXEMPiION FROM WORKERS' Outlats:Ret_light_Sw._ � ���
COMPENSATION INSURANCE - noDRESS- O �
tThis socfion nood not bs com lelsd if fh�work Involv�d b First 20 � �
F�parmif is For en�hvndred dallan(SI00)or lass.) y Total No. Additional CITY . iel.No. �—$[�
MAN CHECK
I certify thot in Ihe performance of ihe work foi wh(ch ihis � . APPLICANT
pe.mil is issued,I shall not employ ony person In ony manner -
so as to become s�bject fo the Workeri Compensation Laws. ��9hting Fixtures First 20 ADDRESS � �
� � � � To�al No. Additionol
Date oPPlicant . . CITY Tel.No.
- Fixed Applionces Nol Over 1 HP PERMiT
�IOTICE TO APPLICANi: If, oflei moking ihis Cerrificote of APPLICANT
�p"mpt�on, you should betome subjact ta the Workers' Range_Heater_D.W._
r.�bmpensotion provisions of the Labor Code,you must(orth- Oven _Dryer _W.M.— � ADDRESS
wiih comply with such provisions er this permit sholl be Top _FAU _—W.H.—
deamed revoked. � � � CIN r���- Tal.No.
�UCENSED CONTRACTORS DECLARATION Hood _Fon _O�her_ .
LI�ENSE OR
I hareby offirm thal I om licansed under provisions of Chapfer9 Disp. ._Room Air Cond. _ r�G.NUnneER Closs.�"—! �
(commencing with Section 7000)of Division 3 of the Business power Apporof�s 8 Large Applionces DISTRICT NO. PROCE ED BY �
and Professions Code,and my license is in full force and effet�. /O �
(.�� n_� Size 8 Type HP,KW,KVA,or KVAR- ! �
license Number L xL�r� Lic Class�.�1S� � � - - U
Up to 1 Incl. FINAL �
l�,�.�.^ nrJ I—'/ `�//� Over 1 l0 10 Incl. DATE � � VALIDATION �
Coniractor Y1_LL� � Date�L19� Ovar 1010 50 Intl. . � F+
❑ r FINAI
I am exempt unde�Sec. Over 50 lo 1001nc. BY �y� ��¢� �uVi
B.BP.C.for ihis reason � Over 100 1 1`�' N
. Services,Sw6d.,MCC 8 Panelboards - ,- - � - � - �� - ? �
Daie: 0-�00 Amp.Under 600 V �
Signoture 201-1000 Amp.Under 600 V � ' -� --
❑ Over 1000 Amp.or Ovar 600 V
Exemp�ion ior Reg,Moint.Eletl.
SINGLE FAMILY Temp.Power Pole&Appurfena�tes
HOME OWNE2•BUILDER DECLARATION Sign wi�h One Branch Circuil
� >reby affirm thal I am exemp�(rom the Controctor i License Additional Sign Branch C�rcutrs � ..R.� O�.a n
�for fhe following�eason(Sec�ion 7031.5,Business ond
Frofessions Code�: � _ �
❑ �. . . . .p .
I,as owner ot the p�operfy,will do the work and the Misc.Conduits 8 Conductorz
strvcture is not in�ended oi offered for sole(Saction O�her(See Complete Fee ScheduleJ_ , I�• •8 3 9 4
704E,Business and Professions Code). � �
CONSTRUCTION IENDING AGENCY , ,' •8 3.9 4� -
I hereby affirm thot ihere is o tons��uc�ion lending agency for ��.1 s�$4
the performonce of the work for which this permit is issoed PERMIT FEE� � (Su6•ToralJ� `� - -� . . . �
(Sec.3W7,Civ.C.). �
� � PIAN CHECKING FEE - - . . . _.
Lender i Name �
. PERMIT ISSUING FEE . � . _
Lender's Address
I certify that I hove read�his appiimtion ond srate that the TOTA�FEE - �,3,� � �
obove informalion is[orteU.I ogree 10 Comply with all Counly � � � .
ordinonces ond S�a1e lows regulating Eledriml wiring,and , .
here6y aulho�ize iepresenlatives of fhis County to enfer opon � . � � � -�
the above•men�ioned prope�ty for inspecfion purposes. S£E REVERSEfOR EXPLANATORY LANGUAGE
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