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HomeMy WebLinkAbout1805A (10) WORKERS'COMPENSAIION DECLARATION 76A663 t0/ei APpLICATl01� FOR ELECTRICAL PERMIT {� I hereby,aflirm tM1a[I have a cerfrfiwte of consent to self insure, CE-BOeG or a certif'�cate of Workers'Compensation Insurance,or a certified COUNTV OF LOS ANGELES BUILDING AN�SAFETY �� copy thereof(Sec.3800,Lab.C.) ' ��1 N�ComParr/N��ST�-/f�� FOq APPLICANT N FIIL IN .. -..- : JOB .. ... . . . Certified copy is Aereby furnished.. . , ,��'Q New Residenlial Bidgs.8 Poojs, EACH � NO. FEE- '���ESS �'- 1&2-Famil d� 5 — S LOCALIT'Y J/ _ � -� Ce tied copy is fited�with�he�canty�buildifig inspection Y,Sq.FL � ry' rtme�9��-�'/ � . .. Multi-famity Sq.Ft. CRO SSSL _ Q ,. � � �i}/,�/ �� � . � �n,� _ __. .... _ .. . . .. _.�. _�_ ,Date(L��=J.�.9�ADP��cant r✓N-ac.�--� Residentiat Swimmirg Pools a�^m_a o� `�. ' '--' - .. . . FIRM NAME N f-/� -� �-�CEHi1FICAlE OF EXEMPTION FAOM VJORKEPS' -'- p���s:Rec_LigM�gw,_ MAi� ��_ry �' � � �-�� � � COMPENSRTION INSl1RANCE � � . -- �-- -- �pDDqESS . . P� _�(Thls aeetbn need rwt be compleled H the worK invdvetl by tbe First 20� permil Is for a�e hundreq ddlare(S 100)or lese.). . Total No. Additional qT /�tJ.E���- a, Tel.Noy67 9 yr _ ��I certify thal'in the performance of the work(or which thie permit . _-- ____....' ._... _.. . �NCHECK - � �ie iss�ied,I 5hall rat B I a ' ' ���NT . . .�.._.. mpoy rry person in erry manner so as m . become wbjee[to the Workers'Compensation laws..,..,, L'ghting Fixtures Frst 20�.- '- � �-���� - ���� -----�-� - -� AD�RESS� ��- -- -�� - ,..... , .. ... � . . . .. .. Total No. Additional . , . . . � Date �� � Applicanb. .�.-. .....�� �...� CITY � . Tel.No. Fiaetl Appiiances Not Over 1 NP TICE.:TO APPLtCANi:�11,;�after�makiry�tMs.Certificate of � PERnai ,�/j ��`�, �emption,you shouid hecome subject to�M1e Workers'Compensatbn - _-_Range.._Heater_.D.W. _ AP�-�CAr7T �se� � •piovisions af the Labor Code,you mus!forthwith compty wi;h such O�en_ Dryer_W M._ ADDRESS � (�, x ��f� �pmvisions or this Permit shall be.deemed revoked. ,..� -. .. .__TOP �— FAU- _.W.H._._ . _ _ .. -_. . .. - . -� C�TY ���,/Q f}�7��' Tel.No,��y�� �� ��� � LICENSED CONTRACTORS DECLARATION-�,�� Hood_Fan _Other_ �I hereby attirm that I em I�ensed�urder.provisions of.Chapter g .. , .__. _ _____ _ . ucer+SeoR � (cwnmericing with SecYion 7000)of D'rvision,3 ot the Business and DiSD. -- RoOm Air Co�. _ � � pEG.NUMBER -- ' � ' Clas�� - ProfeSsiOns Code,and my license is in full foree end�fiect. . . ppyye!Apparatus 8 Larga App�ia�ce9�- -. . _. . DIS7AICT NO. pROCESSED BY � - ��7 2 �y� Size d Type HP KW,KVA,or KVAq �� ��Q1 O� Q Q License Number ���� � Lie.Class C� - .-._ .� ...---UP to 1 Intl... ... .. . . ._.. �. .. FlNAL . . . .... . U . y � .. Over 7 to_101nc1. _. DA�_� .����1 . .._ . . ._.VALIDATION._.- a -Contractor��c�'�'7.t..1G�,� Date� � �- �� � � Q ❑ Over 10 to 50 Inct. FINAL I am exempt under Sec. --���• �- ��� '�' � -. Over.50 to 100 Inc..... __ �,_. �n ' �U . .. . . . . .-`-- _.. ,_- BSP.C.ior this reason Qvc�700 Y�` Q - - . .._. __. ........... . . ..._. _.. __....__..__ ._.. _ ___�_.__._._... Z -. ...._. ____-.. _._... . _ -'- Services.Swbd..MCC&Panelboards.. -�--batei�'�'�����"--" 0_200 Amp.UMpr 60o V Signature . ...20f-�t000AmP-Under�600.V. .` .. . -. . .. . ._ .. .. _ � ..-.. ......` , --. _ _ . .. 18Q�A _--. ❑ Over 1000 Amp.or Over S00 V r Exemptan tor Reg.Maint Eled. �-- -- --- � --� - � � - �-- . . . . ... _ — i, ._ __2 . ____._ . . , - ,. . o o � ' SINGLE FAMILY .. _.Temp.Power Pole&Appvrtenancw. .. �\ HOME OWNER•BUILDER OECLARATION -�""- -�' ' ���"�-��-'-- ����'^ �-�- lerahy affirm ihat I am exempt from the Confrathx'S Llcense Law Sign with One Brench Circuit � °� �1 J.tJ V -'�r the foliowirg reason(Section 7031.5,Busirmss and Professb�s -" �Additional Sgn Branch Circuits-�� � -��- - ... . __ �_, �,,.,_,.,z . Code1� ... _ . e-c i�� J.,_ �U � Miso.Conduits&Condoctors.._-----.._ .._.._ _. .�. .._ . . _.. . .. ._...... _. _ ... . ... . �9,L 2-��'7 ' ❑ I,as owne�of the properry,will do the work antl the s!rudure p�her(See Complete Fee Schedule)_ is rrot intended or offered for sale(Section 7044,Business ... _ _. _ . _. _ . ,_ , and Protessions Codel. . .. _. . ' .. . .. ..... ... CONSTRUCTIONLENDINGAGENCY � - �-�-�-- �- - -- � _ ...__..._.____-._. 1 hereby alfirm that the2 is a eonslruction Icndirr�agency for the performance of the work tor which this permit is issued(Sec.3097, �� PERMIT FEE ���-' --����"�- �� ���---�-��-(Sub-Totat)� -' - � ._ . ..__.•. _.. ._ . .. . Civ.Q�. (� . ' __.._._ _ � _ . ..PLAN CHECKING FEE.-..___ ... -.-.__. ... --_. _. .. ... .. ._. _._ ._..... Lender's Name - ���� � ��- -PERMR ISSUWG FEE_ _... . . _- -- � -� -� - ._�O . .". . . _ . .. . --�.-.' . .. Lender's Address � � � - I tertify that I have read this applicalion and state that Ihe above . TOiAL FEE . _. ._. . ._.__...._. . � . . .___ . _ .._ _ _ .. . ._. _ .. .._._. ._ ... inFormation is correct.I agree to compy�wilh alt Counry oroinances � ana State IaJrs regulatirg Electrical winng,and hereby authorize .. .� . . . . .. � - .. .._. .._ . . ... __ _. _ . �..__ ._._ ._ . _ . .. _ representatives ot this County to enter upon the abo mentioned � � ��' -� - - - ro ta inspection po.poses. --SEE REVERSE FOR EXPLANATOHY LANGUAGE---- _ . . . . _. � _._ . .. /�'���e_ Q/.�'� _ _ . .. SignaNre of Perminee � Date � � C—J . - !.,.''_ :C_:,�_ G��:�. . �, ''-� —�., '� i -~�� { -��;-�--�-��� -� .. + . � , `� i Ic� ` � 'r ; � ' �-��; l� .�, � i: I 1�. . � . �, i � ; r, ; � . �• �- ;� ':; �� ,i 1, , ;:. 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