HomeMy WebLinkAbout1822A IVORKERS'C0�IPENSATIONDECLARATION 76A669 APPLICATION FOR ELECTRICAL PERMIT �
� CE�SO6G(280)
� hereby arfirm teat I have a certificate oe consent to self. COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,o�a eertificate of Workers'Com e -atinn Insurance,or - ' • . � `
� ed c p thereof.(Sec.3800,L . J `� � �h � �
I ���� FOR APPLICANT TO FILL IN - � Jpg • �
�RafcyNd" Company EACH NO. FEE ADDFESS /
� New Residential Bldgs.&Pools
� Certified copy is hereby furnls � � t&2•Family,Sq.Ft. $ � $ LOCALITV�
Ulti-family Sq.Ft, AREST
Cerlified capy is filed with e c nty buildi insp o CROSS ST
idential Swiry ming Pools
depattment. / O RM NAME
DateaLlL'.Cpplican �s:Rec._Light_Sw._ � qODRES �/
First 20
CF.RTIFICATE OF EXEMPTiON FROM WORKERS' � Total No. AAditional ITY- I No. �„ �
COMP6NSATIONINSURANCE PL CK a
(This section need not be compteted iP the work itl�olved APPLICANT � _
— by the permit is far one hundred dollars (S100)or Icss.) � Lighting Fixtures First 20 ADORESs � a
- . Additional
I certity that in the performance oP the work for which this ��, Tatal No. CITY Tel No. U �
ermit is issued,I shall not em lo an y Fixed Appliances Not Over 1 HP .
p p y y per5on In an menner � PERMIT W
so as to become subject to the Workets'Compensation Laws. Range_Heater D.W._ APVLICaNT p.
. �Oven _Dryer_W.M._ �� ADDRE55 y
Date Applicant
- Top ._FAU'_W.H._ � —
- Hood_Fan _Other_ � dT � � .
' NOTiCH TO APPLICANT:It,after making this Certiflcste of Disp. _Room Air Cond._ LIC E OR .
REG.NUMBE - D lasc
ExempNon,y ouu should become subjea tn the Workers' � �
CompmsaHon Provisions of the La6or Code,you must forth- Power Apparatu5&Large Appliances �ISTRICT NO. PR CES56,�eY i
with rnmply with such provisions or this permit shall be $ize&T e HP,KW,KVA,or KVAR � 1 �.
\\
�deemed revoked. . ( 1� . �j��
� Upto 11ncL� � 3
FINAL
� � � Over 1 to 101ne1. DATE � VALIDATION �
LICENSED CONTRACTORS DECLARATION . Over 10 to�50 Incl.� �
I hveby atfirm that I sm licensed under provisions of Chapter ��r 50 to 100 Ine. FINAL - .
BY
9 (commencing with Section 7000)of Division 1 of the 8usi• � Over 100 � � ' � � � �
'ness and Profeseions.Code,and my license is in fuli force and .
effrct: �/ Services . � � � �
License Numb r v��DLia Cla ' 0-200 Amp.Under 600 V � �
201-1000 Amp.Under 600 V �
Contractor Date��.1� Over 1000 Amp.or Over 600 V . � . -
� HOhSE 01VNHR-BUILOER DECLARATION � Temp.Power Pole&Appurtenances - � � � §� $G 2 A �
Sign with One Branch Cireuit - � �
I hereby affirm iLat 1 am exempt from /he ConfractoPs . �'� • • •�•
License Law for the following reason(Section 7031.5,Busi- Additional Sign Broneh Cireuits � ,
ness and Professtons Code): � . ��. . � 2,�� " �
� � � Misa Conduits&Cnnductors � -
� I,as owner of�he propertY.wili do the work and the Other ISee Complete Fee Schedulel— � . •'�.:•!� 2�,O�
structure is not intended or offored for sale (Section - . - ' � , .. .
�7044,Business and PrnTessions Code). �
CONSTRUCTION LENDING ACENCY , O a��.��$Z �
I hereby affirm [hat there is a constmction lendfng aRency � - �
for the performance of�he work for which this permit is pERMIT FEE ISub-Tota1) . . . .
issued(Sec.3097,Civ.C.). � . " , - .
Lender's Name � . PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address �` PERMIT ISSUING FEE � � � � � � '
1 certify that 1 have read this apP��cation and state that the � TOTAL FEE � . �� '
above information is correcL T agree co ply wi�h aIl County . � �
ordinan , and State law r gul ectri 1 wiring, and - - . �
hereb aut orize represe a v s f 'oun to enterupon � . � . � , , ' . �� _ �
the a ove- enlioned pr r tion rposes. SEE'REVERSG�OR EXPLANATORY LANGUAGE � �
�+/`�v � � . \_ .
Signature of Permittee � Uate _ � � �
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