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HomeMy WebLinkAbout1822A (11) 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 _ � � � , - - .____. _ __ , � $� ,\ � i, _ � '' � � ' :�: +' .. ' .r, - -. ''-- _ f:.' �- . ' !._ 'f..� '4� . '.. � /i � .� t �� .��! 'y � j �� .�.' � ! /� � ,- _ ' . . �.I -' —/ o �� ✓ .� �y,r �y 1 �: , � e� f' J � , , #• �vM1 . 0 4 ' 'f: J t� �._ �' = . f�•��, � (•' 1��'�,` . . U ♦ '" . �j �♦. '',�, � . �� �,�� F' I,� . � � _�1 .. t� _, � ' f�� � .. - -- � '�i % . � �/, fr• . 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