HomeMy WebLinkAbout1042A V�'ORKERS'CO�tPENSATfONDtiCLARATION, . 76n66� APPLICATION FOR ELECTRICAL PERMIT � �
CE�806G f2�80)
I here»y atrrm that i heve a certi�cate ot consent to self COUNTY OF LOS ANGELES BUIIDING AND SAFETY
insurc,or a cerliFicate of Workers'Compensation Insurance,or _ - . � �
a certiCed copy thereo[(Sec.380Q,Lap G � �
I //C�—�� �`-.(n� �ji� � FOR APPLICANT 70 FILL IN JOB ' ����1�__
Pnlicy�CJ Company %t'�"/G r v ADDRESS
. � New Residential Bidgs.&Pools EACH Nfl. PEE
� Certified copy is hereby furnished. . 1&2-Family,Sq.Ft. $ — $ LOCALITY�'� 0/1(�
Multi•family Sq.Ft. — NEA E T
i ied copy is tiled with ihe county butlding inspection CROSS 5T .
de a tme t. �1 Residential Swimming Pools OWNER OR /�///�� G�,�
p �� Q FIRM NAME �/{/
Date�� �6 Applicant �"'�� putletS=ReC.�Li9ht_Sw._ MAiL ,� -
� ' . FirS[20 ADDRE55
CGRTIFICATE Of EXEMPTION FROM WORKERS' Total No. AAditional - CI7v ���� /T�aLNo. .
COb1PEN5ATION INSURANCG c� • }
' � APPLICANTK E�IrW s3�1� O
(7his section need not be completed if the work invoived Lighting Fixtures First 20 - qoDRess V
by the permit is for one hundred dotlars (SI00) or Icss.) Additianal ��� �' � �
Totel No. CITY�� Tel No. � �� O
f certity that in the perfarmance of the�vork Por which this Fixed Appliances Not Over 1 HP ��' F�
permit is issued,I shall not employ any persnn in any manner PEAMIT �/ U
-so as to become subject to the Wnrkers'Compensation Laws. Range_Heater_D.W._ . APaLICANT .-7� �1�/�/ W
' � - � � Oven _OryB�_W.M._ AOOFESS o�o�-�� .� ' / S �� N
�Date � Applicant Top _FAU _W.H.._ ��TY ��` Tei No.^� G��p 2
Hood_Fan _Other_ .
NOTICf TO APPUCANT:If,e(ter making ihis Certificate of pisp, _Room Air CondL_ LICENSE OR �G -
F:zemptinn, ynu should become subject to the Workers' AEG.NUMBER � Class .
�Comprnsation provisinns of the Labor Cnde,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PHOCESSED q`
with tomply with such provisions or this permit shatl be Size&TYpe HP,KW,KVA,or KVAR �� �� 1\
deemed raroked. � � Up to 7 InCI. � �
FINAL
Over 1 to 101nt1. on-rE 1 c� ,�� VALI TION
LICENSED CONTRACTDRS�ECLARATION " � Qver 10 to 50 Incl. oL .
i hereby affirm that 1 am licensed under pmvisions of Chapter Over 50 to 100 Inc. . gy'"� � � .
9(commencing with Sectian 7000)at DiviSion]of the Busl• Over 100 ' _
ness�nd ProkSsions.Co�ie,and my ticense Is in tutl force and .
effect. , q - Services � . .
Ltcense Numhrr �S� ¢.Class"� ,'�� �'200 Amp.Under 600 V �
���S�' . �i' ,�// Jr/ 201-1000 AmP.Under 600 V , .
�� �j/a / Over 1000 Amp,or Over 600 V
Contracto Date � � '
HO:�tE 01VNL•'R•BUILDER DGCLARA7JON Temp.Power Pole&APpurtenantes � � - .
I hereby aftirm thst ! am ezempt from the Contrector's Sign with One Branch Circuit � .
�Licen:e Law fnr Ihe tollowina rrason(Section 7031.5,gusl. Additional Sign Braneh Cirevits
ness and Rafessinns Code): � �
� � Misa Conduits&Cnnduemrs � ���A
� I, as owner of the properry.will do the work nnd the pther ISee Complete Fee Schedule)— . ' �
simcture is not intended or oftered for sale (Section . .#�'����• i 2
� 7044,Business and Professions Code). .
COhSTRUC7ION LENDINC AOENCY . •��������5 O .
1 hereby affirm that [hefe is a c9fistructinn lending agency
for the performonce of the ��t�< for which this permit is pERMIT FEE . (Sub-Total) ������� ���'S��
issued(Sec.3097,Civ.C.). - - � • �
Lender's Name pLAN CHECKING FEE (One-Faurth Permit Feel �2�6—8��
Lander's Address � � PERMIT ISSUING FEE � ��
!certity that I have read this apP��cation and state that the TOTAL FEE - �
above lnformation is correct.1 agree to comply with all Cunnty � � . �
ordinances and State laws regulating L•lectrical �s•iring, and _ � �
here6y authotixe representativts of this County to antet upnn _ �
the abnv enC d property for inspec[ion purposes. SGL•"REVERSE['OR EXPLANATORY LANGUAGE
.������— /.�//b/�j
Signature ot Permittee Uate � � � .
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