HomeMy WebLinkAbout0845A (4) WORKERS'CObiPENSATION.DHCLARATION �6A663 � APPLI�ATION FOR ELECTRICAL PERMIT y�
� CESO6G(280)
I here6y aftirm �hat 1 have a certiftcate ot consent to sei[ COUNTY OF LOS ANGELES BUILDING ANO SA�ETY U
insure,or a cerHPcete ot Workers'Compensation Insurance,or �
a Certified cnpy thereot(Sea 3800,Lab.C.) � �
� �. . FOR APPLICANT TO FILL W Jpg �
PoliCy N0. Company EACH NO. FEE /+DORESS D
� New Residentiat Bldgs.&�ools
� Certified copy.is hereby Nrnished. �gi Z.Family,Sq.Ft. $ — a LOCAUTV d
❑ - Multi•family Sq.Ft. — N AR
Certified copy is fiied with the county building inspection CROSS 5T
department. � . Residential Swimming Pools _ OWNER OR -
� c FIRM NAME �
Date � Applicant Outtets:Rec.,.tLight�Sw.� QV qDDRESS �
)/y Fvs[20
. CERTIFICAiL•OP EXEMPTiON FRON WORKERS' Totai No.� AAditional CITV Tel No. � }
COMPBNSATION INSURANCE � '
PLAN CK �-
� APPLICANT � O
(This section need not be completed i[the wock involved Liphting Fixtures . First 20 ADDRESS U
by the permft is for,one hundred dollars (5100)or leu.) Additional � �
' - Total No.�^ . � p
1 certify that in the pertormance of the work for which this Fixad Appliances Not Over 1 NP CITY Tel No. F,
, permit is issued,I shall not employ any person in any manner PERMtT � W
so az to M1ecome subjeat to the W s'Compens . Range_Heater_D.W._ � APPLICANT O u�U e � a ,
Oven _Dryer_W.M._ - AD�RE55 N
Date Applicant� Top _FAU _W.H., . z
Hoad_Fan _Other_ _ � CITY Tel No.�
NOi10E 70 APPLICANT:It.after mak' his Cer[ificate of - Disp. _Room Air Cond._ LICENSE OR
Exemption,�you should 6ecome su6j to the�Wnrkers' . F1EG.NUMBER Class
Compensation provisions of the Labor Code,you must for[h- Power Apparatus&Lar9e Appliantes DISTRICT NO. PROCESSE BV
with comply with such provisions or this permit shai� be � " �-- � �
deemed revoked. Size&Type HP,KW,KVA,or KVAR � 0 .
� . . UP to 1 Incl. �['�'��
� � Over 1 tv 101nC1. DA EL I^ IC� ���Z! .
L[CENS[D CONTRACTORS DECLARATION Over 10 to 50 Incl. � / VALIDA710N
1 hereby afCrm that 1 am Ilcensed under provisionsof Chapter Over 50to 1UO Inc. FINAL � / � ,
9 (commenting wilh Section 7000)ni Division 3 of the Busi• OY2f 100 Bv �
ness and F4ofessions Code;end my license is in lull force and �
efiect. ' $eivices � � ".
License Num6er Lic.Class 0-200 Amp.Under 600 V ,
. 201-1000 Amp.Under 600 V
Contrector �ate Over 1000 Amp,or Over 600 V � .
HOME OWN�R•BUILDER DECLARATION Temp.Power Pole&Appurtenances , � .
f hereby�affvm that I am exempt Rom the Contractor's Sign witb One Branch Cireuit -
License Law for the toltowinR reason(Section 703t.5, Ruxi- Additional Sigo Brench Circuits . . . �- .
nes and prntessiona Code): z"p�4.5 A
� Misa Conduits&Conductors - �
�t, as owner oL the propertY.wilt do the work and the Other(See Complete Fee Schedulel— ��t.• • •�• •z �
structure is not intended or offered for sale (Section
.7044,Business and Professions Code). _ - � • e 3 Q'�O �
CONSTRUCTION LFNDING AOl:NCY . �
I hereby afflrm that ihere is a construnion lendeng agency • • •�Q'�Q� ,
for the performance of the work for which this permit is pERMIT FEE � (Sub-Total) � �
issued(Sec.3097,Civ.C.). � � '��Q_8��
Lender's Name PLAN CHECKING FEE (One-Fourth Pe�mit Feel �
Lender'sAddress PERMITISSUINGFEE ��G �
(certiCy that I have read this appiication and state that the TOTAL FEE Q ,�
ahove intormatlon is correct.1 agree to comply with all County � . � .
ordinances and State laws regulating Electrical wiring, and � . ,
hereby nuthorize repres tives of his Counly to enter upon � . . - . ,
the ve ientioned p o ty for spection purposes. . . �
SEE-RBVERSE FOR ERPLANATORY LANGUACE -
Sigeature o ermlUee Date /_ . ' � .
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