HomeMy WebLinkAbout1338A WORKERS'COMPENSATIONDECLARATION � 76a663 ,o�e� APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm�hat I have a certificate of.toosent fo self �"� . . .
ins�re,or a certificate of Workers'Compensation Insurance, COUNTY OF LO$ANGELES BUILDING AND SAFETY
or a cerlified mpy ihereof(Sea 3800,La6.C.) - .
P❑olicy No. � Compony iOR AAUCAM TO flLl IN . JOB � �1 � .
Certified copy is he�eby furnished. New Residantial Bidgs.8 Pools EACH NO. �FEE ADDRE55 �11�/
� � 182.Famil Ff. E � — E LOCALITY� .
Certified topy is filed wifh the county building inspec- Y•�• rIFnREST
tion deportmen�.� � - . MuNi-family Sq.Ff. - —
Residential5wimmingPools � GrtoS557.
Date Applicont . . , a � OWNER OR
j`��A"'�—' , FIRM NAME
CERTIPICATE�OF EXEMPTION FROM WORKERS' Oufle :h Ret—lfght_Sw._ - �"��
COMPENSATION INSURANCE � � � �nDDRESS -
Thfs sMfon need nof bs com lefed if ths work Involved 6 First 20 �
( P Y Totol No. - CITY Tel.No.
fh.P�rmif is for oe�hundr�d dollan(5100)or Ins.) Additionol
I certify that in the performance of'the work for which this . � _ . � qP�PL�iC�,c,NT� � � �
permit is issved,I shall not employ any p on i y manner .
so as to betome wbjecl ro the W� o pe s 'on Laws. Lighting Fixtures� First 20 ADDRESS� �
Total No. Additional
Date_�;�ApplicaM CITY Tel.No.
NOTICE TO APPLICA T: If, ofler makin this e�li i �of Fixed Appliances Nat Over 1 HP PFRMIT .
Exemplion, yoo should 6ecome subjetl �o the W ers' . Range_Heoter—D.W._ APttiCa'M ,
Compenwiion provisions of the Lobor Code,you must rth- Ovan._6ryer _W.M._ ADDRE55 � � rv�,� �
with tomply with svch provisions or this pe�mi� sha be .Top _FAU —W.H.— .
deemed revoked. � � - Hood _Fan _Ofher_ - CITY Tel.No. ' .
� � LICENSED CONTRACTORS DECLARATION uCEN -
�I hereby oHirm tha�I am licensed under provisions of Chapier 9 Disp. —Room Air Cond: — REG.NUh�eeR - - - Clau.
(commencing wilh Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances . . DISTRICT NO. PROCESSED BY �,
and Professions Code,and my licanse is in full force and effed. - - ���� �- � p�
��r}-� � � Size&Type HP,KW,KVA,or KVAR� Q
License Number���2 Lic.Class� �� FINAL - � V �
Up to 1 Ind.� DATE ✓ra- �
'��',Q� Over 1 to 10 Incl. . �� � lJ � VAUDATION - Q
Conlmctor� Dme� Over 10 fo 50 Ind. FINA � . V
❑ I om ezempt under Sec " � � � Over 50 to 100 Inc. . BY�� ��, ,�± �f . . . s++
B.BP.C.for ihis reason �°e��� . u�`t��� 2 �
� �ate: - Services,Swbd.;MCC 8 Panelboards ► � -� � . � - — '
0•200 Amp.Under 600 V -
Signafure � 201�•1000 Amp.Under 600 V � � - �� �
� , . , Over 1000 Amp.or Over 60D V . �
Exemption for Reg.Maint.EIeU.�
SINGIE FAMILY . Temp.Power Pole 8 Appurtenances � . . - . . '
HOME OWNER-BUILDER DECLARATION Sign with One 6ronch Cirtoit . - .
I hereby affirm that I am�ecemp�from the CoNracror's litense Additionol Sign Bronch Cirtuits -� -- - �
Low for rhe iollowing reoson(SeUion 7031.5,�Business and - �- �
Professions Code): . � �
� M:sc.Conduiis 8 ConduUors - , � �� J�$A—
I,as owner of the property,will do the work ond the -
� sirocture is nol iMended or oHered for wle(Section Ofher($ee Complete Fee Schedule)_ � _ . . , . ,�,• •-o • •`� . �
7044,8usiness and Professions Code). � . .
CONSTRUCTION LENDING AGENCY �� �- - � � �3 a�� �
I
I hereby affirm that there is a constrottion lending o9ency for � ����• •3 Q 5.0�
fhe performante of fhe work for whith 1hi5 permit is iSSved � PERMIT FEE -- � �� - -'� ($ub-Tolal) �� � � . - ,
(Set.3097.Civ.C.). . � . . .
. � � .. . , - PIAN CHECKING FEE� - . . . . . . �2 O� �8 4 , .
lender's Name � � � � �
� � - - PERMIT-ISSUING FEE � Q _ . .. ._ ._... �
Lender's Address � � � � '
I certify ihoi I have read this application ond state Ihat rhe TOTAL FEE � � Q,Se . . _ �
obove iniormation is correct.I agree to comply with vll CoaNy . . . �
ordinances and Siate laws regu aling Eledritol wiring,ond � � , . �
reby �horize re ntaf i ihis County 10 eMer opon �. � . - � - ��
1he o6o e entio d pr er ,f inspedion purposes. � � �
SEE REVERSE FOR EXPIANATORY LANGUAGE
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