HomeMy WebLinkAbout1595A (9) � \VORKERS'COfitPENSATION DECLARATION 76A663 APPLICATIC?N FOR� ELECTRICAL PERMIT � r,�
� - - CE�BO6G 12�80)
I hereDy atfirm th�t 1 have a certiricste or coneent to se�f COUNTY OF LOS ANGEL�S, BUILDING AND SAFETY �J
insure,or a certificate ol Workers'Compensation Insurance,or . . � �
a certified copy Ihereof(Sec.3800,Lab.C.)
TP.Q6U '*p 7.577�8Z State F ' FOR APPLICANTTO FILL IN JOB
� 1'olityN� �ompBrr7 EACH NO. FEE ADDRESSI,3F)5I Palomino Dr.
. New Residential Bldgs.&Pools . _
� Certified copy is hereby furnished. • . 1&2-Family,Sq.Ft. $ — $ LOCALITY DS8IIIOAd Bar
� Multi-family Sq.FL — N p' ' .
Cettified copy is filed wlth the county buiiding inspecti CRO55 ST
department Residential Swimming Pools OWNER OR
�'1 /',,,(I(� FIRMNAME Joseph Maudlin
Date�3�pplicant �Mets:Rec.2L�ght_Sw._ MA�� Same
/ � �� First 20 ADORESS
CERTIFICATE O�EXEM1IPTION FROA1 WORKtiRS' Total No.�� Additional dTV .Sd�e Tel No. G- }
" CODIPENSATfON INSURANCIi . � PLAN CHECK �
- � APPLICANT " V
(This section nced not be compieted if the work invalved Lighting Fixtures First 20 qDDREss �
by the permit is for one hundred dollars(5100)or lessJ . �
Additional Q
� Total No. - CITY Tel No. - �—
I certify that in the performante nf the work for which this Fixed Appiiances Not Over 1 HP
permit is issued,I shall not employ any person in any manner � peanniT V
so as fo become subject to Ihe Workers'Compensation Lau•f. Range_Heater_D.W._ � APPLICANTAZUIItd�K001 W
O�en _Dryer_W.M._ AD�RESSISZS E. Washington B2. Z
Dale Applicant � Top _FAU _W.H._ � C17V 7el No.
Hood—Fan _Other_ LOS An eles 798-7Z91
NOTICE TO APPLICANT:1f,after making this Certificate of Disp. _Room Air Cond._ LICENSE oa 260890 � �
Exemption, you should become su6ject to the Vlnrkers' REG.NUMBER Class
Compensatinn provisinns nf the La6ar Code,you must forth- power Apparetus&Large Applianres DISTRICT NO. - PROCESSEO BY �
with comply with such provisions or this permit sMll be Size&Type HP,KW,KVA,or KVAR
deemedrevoked. . . �UptollnCl. � /O f�
FINAL
� . Over 1 to 101n[I. � DATE� VALIDATION
. LiCENSrD CONTR,4CTORS DECLARATION Over 10 to 50 Incl. �
I hereby atfirm that 1 am licensed under prnvisions of Chapter Over 50 to 100 Inc. B�.n [ � ,. .
9(tommencing with Section 7000)ot Division 3 oi the Busi• Over 100 �/� �
� ness and Professions.Code,and my license is tn fult torce and ' .
efiect. ' Services
License Number Lic I855a1� C61 0•200 Amp.Under 600 V _ .
207•7000 Amp.Under 600 V
Contractor - � Date��_ Over 1 D00 Amp.or Over 600 V �
� � •r
- HOM14E O�VNER•BUILDER DECLARATION Temp.Power Pole&Appurtenances ' � .
I hereby atFrm th�t 1 am exempt from the Contrector's Sign with One Branch Cireuit � .
License Law for the following reason(Seclinn 7031.i,a�5f- /+dditiana�Sian Brench Cireuits. . . � �1 5 9.5 A .
ness and Rofessions Code): . � � � ��� .
� Misa Conduits&Conductors �� � 2 "
� 1, as owner of the property,will do the work and ihe Other(See Complete Fee Schedulel— . � • •�.�9.']�
structure is not intended or offered for sale (Sectinn
T044,Ausiness and Professions Code). �' x �
CONSTRUCTION LENDING A(31:NCY •.�• ••�9.7��''
1 hereby affirm that there is a conslruction lending egency �
Por the performance oP ihe work for which this permit is pERMIT FEE � (Sub-Totaq .�2'� $,—8�2
issued(Sec.3097,Civ.C.). �� � -
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Fee1 � ,
I.endePs Address PERMIT ISSUING FEE ' ��G' .
i certify that I have read this application and stale[hat the TOTAL FEE � �� �
above iniormation is correct.I agree to camply with all Connty ,
ordinances and State la�vs regulating Electrical �viring, and - -
hereby authorize representatives of Ihis CoUnty to enter Upon � � - '
the abme-mmtip . roperty f 'nepection purposes. SEL'RLVERSE FOR CXPLANATORY LANGUAGE •
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SignatureofPermittee . te � � - '
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