HomeMy WebLinkAbout1781A (10) WORKERS'COMPENSATIONDECLARATION 78A683 +o�a� AppLICATION FOR ELECTRICAL PERMIT. - � I hereby affirm thal I have a certificate of consent to Selt fnsure, CE-808G w a certificate of workers•C«ncensatbn Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy there .3800.Lab.C.) �/ Po,;�v No. J.9o/�3lc3�o,,,pe�NQ(�,�jJ��JJC� FOR APPLICANT TO flLL IN - ' JOB D�- ❑ ,Certified copy is hereby,lurnished. � � . ��'� New ResidenYul Bldgs.&Pool � EACH NO. � FEE ADoaess� `-���Certified copy is filed�with the � nty building inspection �g 2•Family,Sq.FL� S — g LOCALIT � �T � . " ment./. - .. •. . .-.:., � - �� MUltl-f8mily Sq.F�. — NEAREST,. , . � . . .. ... /�{/ .., . ._ ._ . CROSSST., - :. ... .- 'Date dC/� Applicant ftesidential Swimming Pools , - � ��--- - pwNER ofi n � . .. . �- . , �. . � . .. . .. . FIRMNAM .�/ 7L� �. � CERTIFICATE OF EXEMPTION FROM WORKERS . � � ' Mqi� �7 � p -� � � �COMPENSATION INSURANCE -�.-�, �. �lets:Rec—Light_Sw.— � .. . . '. ADDaEss �.V• .�� �/ (This sectbn need not be completed H lhe wotk involved by the First 2�. . permR Is for one huadred dollare(5700)a lesa.) Total No. Additbnal-�- ��T (�N ��a Tel.N.�'��6�!/ � �� . PLAN CHECK � - .I cerHfy that in the peAormance of,the vrork for which ihis permi[ - �� -- � APPLICaM��- - - ' .is issued,I shall not employ arry person in any manner so as to ' _ _ _ � - � � �� �- A�DFiESS -- hecome�su6jetT to the Workers'Compensation Lavrs.-, ,_ Lghting Fxtures Frst 20, --�-- -----. �- . � �. . . � .. .�.. .'. ;...�., � Total No. Additional. ___.._ . _.. . Date �. Applicant . . , CITY- Tel.No. Fixed Apptiances Not Over 1 HP PERMIT .� . �T10E-.TO APPUCANT: IF,.e(ter making this.CertNicate of Aa�iCnM�� �(, / L �mption,y0u should beCome SubjeCt to lhe Workers Compensafan . Range_Heater D.W. _ _.. . . . .. _._'_. .._. . . _ .provisions of the La6or Code,you must forthwith comply with such Oven�_ �ryer_ W.M._ ADDRESS ,[�, �/�/� � . �- ,piovisions�or,this permit shall be deemed revoked. . . Top__FAU _ W.H._ _ (y O� G� _ . _ .. __ .. ... _ . . _ . CITY fN - 7�7�6 Tel.No�/��A�b - ,..LICENSED COMFt4CTORS DECLARATION � . Hood—Fan _ Other_ .I here6y aifirm that I am licensed�under provisions�ol,Chapter 9 uCENSEOR ry� . ...�I�g��_ �-DiSp. _Room Aif Cond..-_ pEG:NUMBER (eommencing with Section�7000)of Division 3 0l the Business and O Professions Code;and my license is in full}orce and eltect: � � DiStaiCi NO. � paOCe55e�ev Power APParatus&Lar9e APpliances. .. .._. . _ . ..__ . .. _ ...._ ___��. .. .._..._.. ������,,,...,�,�,1 f l/:,.,l� ^/v Size 8 Type HP,KW,KVA,or KVAR (� � � License Number.f��TU Lic.Class 4 ..` .� . .....' UP fo 1 incl."-. .... . -" . . --� � � FINAL . . ..---. .-. . . ._.. . ._.'-.- ,�^7� ,��/ � . .... .. Over 1 to 10 Incl. � DATE.. .(� ��I� . ...� VALIOA710N a '"Confractor ���v"�`F�� Date� Over 10 to 50 InG. � � - � � ❑� I am exempt under Sec. - ___ __, ' Over 50 to 100 InC.. FINAL V .. ______.. . ....._ . . . . . _..__. .. . .._.._ 8&P.C.for this reason Over 100 N' �-- �Services;Swbd..MCC&PanelboaMs ... - .. ...-.. . , - . . . . -. ... Z - _ oa�e: _-- o-zao a�.u�ee�soo v �1 7 8 1 il � Signature --- ---201-1000-Amp.Under 600 V---- - �- - - ------- -� �- �� � -�- - ._ __._ .. ... _._ _ .._._..._._._.___ _- ._. . O�r 1000 Amp.or Over 800 V . #• • • e a 2 � ExemPtan for Reg.MainL Elect. __ _ . __...... .. _ . ._ _.-._." .... . ... _.. _. .... __.___._ .- -- _._ . _ .. . _ - - - .._. .--- . ...._..�- ..- S�NGLE FAMILY---... .. ......��". TemP.Prn+�er Poie&A I ° °� �'9 4 . ppurtenances 1 HOME OWNER-BUILDER OECLARATION '- " -� "� '-" �"' �-"� --��� �� -�-��- Yreby aHirm that I am exempt from the ContraMor's Lieense Law Sign with One Branch Circuit �" ���' -� �---� -� ��-m- �U�� ��-=� -��r the folbwirg reason(Section 7031.5,Business aM Professions- �-- Additional Si9n Branch Circuits._.. __.._ ...... . . . _ coae>: , _.. -D 9:�2-R F . � . _ Misc.Conduits&Conductors--.- .... .. - - .._. - ... _. _.�._ . . . .- - --_.. -. - . .... I,as owner of the property,wili Do the work arM the structure is not intended or otlered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ , . .. .._... . .. . . __ _._ __._.. .. _._._ _. . _ _ and Pivfessions Code6 . . . . .. ".. . - .. . CONSTRUCTION LENDiNG AGENCY � � - - -� - � -- . . . ..... .......... . ._ __. .. I hereby affirm that there is a construction lendirg agency for the ' performance of the work for whtch this permit is issuetl ISec.3097,. . .pERMR-FEE -- �-- -- � � � �� �� (Su6-Totaq - �� _ _. . _ ...... _ ..... . _.._ _.-_ . __ _. _ � Civ.CJ. _ .PLAN CHECKING FEE. _.._. ..._ . . .. _. . � Lender's Name - _._..._ . .. . . . . . . ..__._... - .-- � PERMT ISSUMG FEE, . � (, � , _ ._._ . .... . . Lenders Address . .. - ._. --.. .. .___- . I certify that I have read ihis apP��ation and sfate that ihe above „ ,TOTAL FEE _ __ � � � ., • ._ . . .. . _. . _. ._ . ._. ..._... -- - information is correct.I agree to comply with all County ordinances - and State taws regu�ating Electrical wirirg,and here6y authonze representafrves of this Counry to enter upon the above-mentioned ���-��� - ��-� " "��� "- -- - �"-� - -- - �- � "- '�" " - �"� '� -- �- ���� - -� -'��- -'�-- --- � prope or ir�spectian purposes. � ��� �� 9 �� . . 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