HomeMy WebLinkAbout1474A WORKERS'�OMPENSATIONDECLARATION ���� �0�81 qpp��CATION FOR ELECTRICAL�PERMIT � 1
I here6y offirm thol I heve a cerfifica�e of consent to self ���CE-806G _
ins�re,or a tertii�cate of Workers'Compensation Insurante, COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
or a ceitified topy rhereof(Sec.3800,Lob.C.) � ' �
����6 5 3 e R 8 3 comao�y �n 5. C Q. �e S,t FOR APPIICANT TO Ntl IN �oa
Certified copy is hereby furnish New Residenfial Bfdgs.8 Pools EACH NO. FEE ADDRE55 2�2� Mo n i t e a u
•� Certified copy is filed with Ihe co_1y u�ding i spec- 1 8 2-Family,Sq.F. E = E �OCA��TY D 1 81110 fl C� B 8 I' �
tion deparlme�f. � Multi-fomily Sq.Ff. NEAREST
� �'� �(t� CROSS ST.
D o f e�L,—L A p p i i c o n t Residential Swimming Pools OWNER OR
FIRM NAME B r a d 1 e o n e s
' CERTIFICATE OF EXEMPTION FROM WORKERS". ��� �
� COMPENSATION INSURANCE � . Outlets:Rec_light_Sw._ ADDRE55
Firsl 20
(This s�cNon nNd noT 6s complsfed tf 1hs work tnrolved y Tolal No. Addiiional CIN - Tel.NS(�--��i 3 3 �
1hs perm�f h(or ono hundr�d dollars(5�00)or loss.)' vinN CHECK � � �
I cerlify ihot in the periormance of Ihe work for which�his . - � APPtICANT _ �
_ parmit is issued,I shall not employ any person in any manner � _
so as to become subjed lo the Workers'Compensofion laws. lighting Fixtures First 20- � ADDRESS �
� ' . . . Total No. Additio�al �ITY - Te�.No. �
Da�e Applicdnt - Fized Applionces No�Over 1 HP PERMIT
NOTICE TO APPIICANT: If, af�er making rhis Carlifica�e of � . APPlIC4NT E(1 V I,r0�I fI�C�l Y a� E n �
Examption, you shoold become sobject 10 the Wo�kers' Range_Heater_D.W._ _. .
Compensarion provh�ons oi the lobor Code,you mus�forih• Oven _Dryer _W.M.— . ADDRE55� �
wi�h comply wilh such provisions or this permit shall be Top _FAU —W.H.— �
� deemed revoked. � - Hood _Fon _Other_ CITY 0 r a n g e Tel.No.(3 -8 Q 8� ,
� UCENSED CONTRACTORS OECLARAT�ON � uCENSE Ort
I hereby offirm Ihat I om licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER Closs.
� (commenting with$ection 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY
� ond Professions Code,and my license is in full force and effetl. Power Apparalus 8 Lorge App�iances . � � � �� .
Size 8 Type HP,KW,KVA,or KVAR� � O '
' Licenze Num6er 3���48 Lit.Class C44 . � . _�� - - c� FINRL - �� ,• -�� V
. Over 1 to 101nc1. DATE 'L Z�/y� . YALIDATION � .
�! Controctor F�y 'r n�a Da�e 2-.�-.R L Over 10 to 50 Ind. ' _ / O. ,
�, ❑ . . FINAL / .._ . _. .. V .
I am exemp��nder Sec. Over 50 to 100 Inc. BY /�r�ry/G �+
Over 100 Lf(/I"(LG . a' .
8.8P.C.for this�eason y
' Services,Swbd.,MCC 8 Ponelboords ► � ? '
'� Date: 0-2IX1 Amp.Under hW V �
� Signature 201-1000 Amp.Under 600 V - ' � �.
i ❑ . Over 1000 Amp.or Over 600 V '
Exempiion for Reg.Moint.Elect.
- SINGIE FAMILY . Temp.Power Pole 8 Appurtenonces . .
HOME OWNER-BUIL�ER DECLARATION Sign wi�h One 8ranch Cirtvit � . �
�I hereby affirm rhat I am exempt from the Convac�or's License Additionol Sign Bronch Circuiii � � � � - �
�Law far the fallowing reason(Setlion 7037.5, Business ond ." �� �J.7,�l a
!P�ofessions Code): � �
'�.❑ I,as owner oF the property,will do tbe work and the Miec.CondOiis 8 ConduUors � � " � 2- �.
. • • • •
5lrudure is nof intended or offered for sale(Section _ Other{See Complete Fee Schedule)_ ► _ � �
7044,Business and Professions Code�. I • • � 4.�J 0 �
�i CONSTRUC710N tENDING AGENCY • • •1 4 5 0�
I hereby afiirm that�here is a conslruction lending agency for • '
�,the performonce of the work tor which this permif is issoed ���- pERM1T FEE - -- �- - ' (Sub-Total) � � �� - -- � -- -�� �� �Z� Q'8[� �
�(Sec.3097.Civ.C.). � .�.
! � PLAN CHECKING FEE � - � - � - .
�Lender's Name
PERMIT ISSUING FEE... fO SU � . . . . ,
�lender's Address � -
�I certify tha�I hove read�his opplicaiion and slate ihat the - TOTAL FEE /�SC � • . _ , . .
obove information is torred.I agree to comply wi�h all Coonty � • � � �
ardinonces o $taie lows regulating Electrical wiring,ond � _ _ _ , .
her autho ze repie entatives of this County to enter upon , , � � ���- -- .
ihe a ve-m n ed raperry for inspection porposes.
SEE REVERSE FOR EXPIANATORY tANGUAGE
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