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HomeMy WebLinkAbout0949A WORKERS'COMPENSATIONDECLARATION 76A883 �o�e, qppLICATION FOR ELECTRICAL PERMIT �1 � I here6y aifirm ihal I have a certificate of consent to sell insurE, CE-BO6G L I . II or a certifieate of Worke's'Compensation Insurence,or c ified / COUNTY OF LOS ANGELES �� /�jUILDING AND SAFETY Lj co�hereo ( c.3800.Lab.C.) Y /- �� Poli No. an /, FOH APPLICANT TO FIIL IN � �� JOB- ��Certified Copy is hereby fumishetl. . , New Residential Bidgs.&Pools � EACH NO. FEE. . /DoaEss Certified copy is fited with the county building inspection 1$2-Family,Sq.Ft. � — 5 LOCALITY . �� � �depa/tme � -�� � � Muiti-1�rltily Sq.Ft. — NEAFEST � R=siden?izl Swimming Pools CROSS SL� Date Applicant� �D. � pWNER OR � C RTIF ATE OF EXEMPTION FR WORKERS'�� � - --. � FIRM NAME ' Outlef3:ReC_LIgh2_$W._ M^�� � � . CDMPENSAT�ONINSURANCE . . AD�RESS � � (Thls sectlon nead not be completetl If lhe work Involved by the First 20 . permit is for one hundred dollars($100)ot lesa.) � Totat No. Addilional� � CITY Tel.No. I certify that in the performanCe ol the vrork for which this permit , PUN ChiECK Is issued,1 shall not emp!oy ary p2r5on in arry manner so as to " aPPLICAM become subiect to the Vlorkers'Comprnsation Laws.- L'ghting Fixtures First 20� A�DRESS � � � �' � � � � � �-. ��. TotalNo. Additbnal � � Date Applicant CITV- Tei.No. NOTICE �TO APPLICANT: If, after m2kin9�.this Certificate ot Fzed Appliances Not Over 1 HP PERMIT ,` y� Exemption,you should become subject to the Workers Compensation Range_Heater D.W. _ APPLICAM ' r v\ �1 provisions o(lhe Labor Code,}rou must forlhwith comply with Such Oven_Dryer_ W.M._ AD�RE55 uQ pravisions or this permit shall 6e deemed revoked. " Top —FAU _ W.H._ � CITV Tel.No. UCENSED CONTRACTORS DECLARA710N � Hood—Fan _ Other_ � Q`ti — . I hereby atfirm that I am licensed ur�cr prrnisions�ot Chapter 9 uCENSEOR � (COmmfnCing With Section 7000)Of Division 3 of thC BUSinE'SS�nd ' Disp. _Room Air Cond.. � , REG.NUfJBER - � C��s�� � PIO�eSSi0n4 CAdC,�nd my litense i5 in full torCe and ef(ec}. DISTRICT NO. PI70CESSE Y Power Apparafus&Large Appli�nces O � . .. . .. . . ..... . .�.�5`JS�_Lic.Class S_.�lL. _ Size 8 TYDC�jP�y�p'y��V�A�GC . . . O License Number -��� ---�'U d -� - FlNAL �� �� � �� U �,_JI,,,/ Z Over 1 to 10 Incl. DATE � � '�Contrector�l�(�.(�OatB' �3�� � .. . � VALIDATION Over 10 to 50 InCI. � ❑ I am exempt under Sec. Over 50 t0 100 Inc. gyA �'� U B.&P.G.for this reason Over 100 a . ' �-- Services,Swbd.;MCC 8 Panelboards � �-� � �� N - Date: 0-200 Amp.UMer 600 V � Z � Sipnature 201-1000 Amp.Under 800 V-� - - - � � . . . . _.. �❑� � -' � -� - - � Over 1000 Amp,or Over 600 V Exemption for Reg.Maint.Eled. .. . ... . . . .. . . . . . . . , ,. . . ._ . � ' - � � - � -SI':GLE FAMILY � - -�- � Temp.Power Pole&Appurtenances HOME OWNEF-BUILDER DECLARATION Sign with One Branch Circui[ � �� � � -�� -- �� 1 hereby affi�m that I am exempl irom the Contrador's license Law for!h�r^'�m•^^^•^,�^n(S^c!ian 7Q37.5 a^��^^�s^^^a,.�......:...... Additional Sion Branch Cirwits ... . . .... . . ..-' -- .. _._.._.... ____. ,__,,,,,,,,, ,,, ,,,,,,,,�,,.. Code): ❑ I,as owner of the property,will do ihe work and the structure -Mis6 COnduits&ConductoB - � �- � � � �- '��9 4.9 A . is not Intendetl or ofiered for sale(Section 7044,Business Other(See Canplete Fee Schedule)_ � #� � � �� and Prolessions Codel. .. .._ . .- ... .". . . . . - - -- CONSTRUCTION LENDING AGENCY . . - . . . . __ . . _ ._ __ .. ( • • � ��5 O - I hereby affirm that there is a eonstruction lending agency for the ,' perFormance of lhe vrork ior which this permit is issued(Sec.3097, pERMiT fEE �� � �- -- � � (Sub-Total) -... . ' ' '� �,��� Civ.C.). . _ .. _ . . - PLNJ CHECKING FEE . • o e.i �—a a Lender's Name - � � � PERMIT ISSUING FEE Lender's Address . . ..... . . ... ..... . I certify that I have read this appl'�cation and state that the above TOTAL FEE • . . _. . .... .. � .. . ._ . information is correct.I agree to rnmply.with all County ordinarxes � - �- -- �- �" � antl State laws regulaling Electrical wirirg,and hereby authorize representatives of this County to enter upon the a6ove-menlioned � " - '� ��� - �- �� - �� -� �� - � � � property fo�inspecti� p p,es. � .... ..SEE REVERSE FOR EXPLANATORY LANGUAGE _ .. _.. . . . .. . lJ yl /� Sign 1 Permittee Date / ..."�:. --,.... <. .:.:_ .. ' , �----�; �,- - �- i_ -�- _i--;--i i i i : . "--� . - � i�\�.,' �` �. - , � I i � ! i I . ..i 7 . I=� � !'� __ - _ i i II � i i 1�.:'�; _ `�`' -.`� ' - ;_- ` ; i ; 1 ' ; ; i'; i i.:._ 1:� ' . i - �, � � 1 . _ . ,`• ; i i > ` _ I il i i � \ i�` j_ � ' i � � ; . • i I y'� -� i `'� � �._ . _ . .. ��. . �_`� � � � � � : • 1 � l�� _ 1 j � 1 �Ij , { � 7 T C � T �� 7J C -a �� � . j• ,V„i Z '� � X' �. 0 Z � .�' . I.: � i � . i � �. 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