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HomeMy WebLinkAbout1804A (10) WORKERS'COMPENSATIONDEC�ARATION �ba�3 �o,B, APPLICATION FOR ELECTRICAL PERMIT � I hereby affirm tho�1 have a rertificate of consent to seli CE-806G insure,or a certifica�r.of Wo�keri Compensotion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFBTY or o certili 7o��,� py thereof(Sec.3800,Lab.C.j PolicyNo`���� Company�NDG�'rTh/�r_y.; fORA�fIICANTTOFlIIIN. � JOB � Cerfified mpy is hereby iwnished. /q� New Residenfial 81dgs. ol EACH NO. FEE ADDRES5 /�. /�� DiG. � Cerlified copy is{iled with the unly building inspeo I 8 2-Fomily,Sq.FI.-� s — E �OCALIT�jfi �J �' depar enL � � Mulli-family Sq.Ft. NEAREST O /��M ResideMial Swimming Poolz OWNER OR G�,`• DOtO� ApplitOnl FIRM NAME CERTIfICATE OF E%EMPTION FROM WORKERS' Ootlets:Rec_Light_Sw._ �� ��� /�� Q [� � - �� COMPENSATION INSURANCE ADDRESS .U• i0(/X ✓�a/ h(s sxtion nNd nol b�com I�}od tf ih�work fnvolv�d 6 First 20 R P Y � CIT Tel.N � . fh�p�rmlf is For one hundrod dollar�(5100)or I���.) TO���NO' Additional /`�d �7J�-' �I tertify ihet in the perfo�mance of�he work for which ihis APPLICANTK � _ permi�is issued,1 sholi nof empioy any person in any manner — so as ta 6erome svbject to Ibe Workeri Compensation Laws. Li9hling Fixtures First 20 ADDRE55 . � � Total No. Addilionol CITY Tel.No. Dafe 6pp�ican� Fixed Appliances Nvt Over I HP PERMiT �OTICE TO APPLICANT: If, affer making this Certifimte O( APiLICANT'/ �� ` r emption, you should become subject to the Workers' - Ran9e_Heater_D.W.� Compensoiion provisions of the laboi Code,you must for�h• Oven _Dryrr _W.M._ A�ORESS ��, X ��/ with comply wi�h s�th provisions or this permil shall be Top _FAU —W.H.— deemed revoked. � �Hond _Fan _Olher_ CIN /�.('J 9i ��' Tel.N� �p � � LICENSED CONTRACTORS DECLARATION� ���N�� C�O Disp. _Room Air Cond. — REG.NUMBER Closs. �hereby affirm that I am licensed unde.provisions of Chapier 9 �= (commencing wi�h SeUion 7000J of Divislon 3 of the Business . . DISTRICT NO. . PROCESSED BY n- and Professions Code,and my Iicense is in full iorca and afFect. PO`^'e�Apparotvs 8 Large Applionces J� (� � p' �) Size 8 Typa HP,KW,KVA,or KVAR� '�v � \'�0.`d V license Number � � Lic.Class � �" FINAL � Up to 1 Incl. � I [�� .�y��'�/ � Over 1 to 10 Incl. DATE C� �ll�� VALIDATION E"' -Controctor�r[�f�" 'n� �Date Over 10 to 50�nd. V ❑ FINAL � . . , a I om eiempl under Sec. Over 50�0 700 Mc BY �n,_/ Over 100 � �v� � 8.8P.C.for this reoson Z - Dme: � Services,Swbd.,MCC 8 Ponelboards � �� g p,4 q 0-2W Amp,Under 600 V . Signatore 201•1000 Amp.Under 600 V �• � ° • �G ❑ � Over 1000 Amp.or Over 600 V . . Evemp�ion for Req.Moint.Elect. I • � � Jr.�D SINGLE FMdILY Temp.Power Pole 8 Appurtenonces �� o , '{�� ��;p� � \ HOME OWNFR-BUILDER�ECLARATION Sign wilh One Branch Circuif Jhereby offirm tha�I om e�emp�from�he Controdor's license Addinonol S�gn Bronch Circui�s - O Q,2 2—�H "`Law for the following reoson(Settion 703I.5, Business and � P�ofessions Code): ❑ I,os owner of the Misc Conduits 8 Conductors properry,will do the work and�he Olher See Com le�e Fee Schedole_ shvcture is not in�ended or offered for sale($edfon � P. � , - � � 704a,Business ond Professions Code). � . CONSTRUCTION LEN�ING AGENCY � I hereby affirm that Ihere is o construtlion lending agenty lor ihe pertormonce of�he work for which fhis permil is issved PERMIT FEE �� - (Sub-Total) /b S (Sec.3097,Civ.C.). . . ' PLAN CHECKING FEE - � � Lender's Name f � PERMIT ISSUING FEE U . � lender's Address � I certify that I have read this application and srate thot�he TOTAL FEE obove informo�ion is torrect I ogree to comply with ail Couny - ordinances ond S�a�e lows regulating Electriml wirinq,and . � - hereb ou�horize represeNatives of this Coonty to enter upon � �h ove•menfioned properfy for inspecfion r es. - M/,,,y,,/���,, �� SEE REVERSE FOR EXPLANATORY LANGUAGE !/ /c..(\[y�r Signa�we ef Peiminee Dare . } . ,;- ���\� Y,` 't�•r,�� - _ . - � `r 1 / ` � ! i/ . �! �`;� ) `` ` � ' ` , � �/ vt •, �` 'I , f / � � �� 1 .• , /..I ',.. /• � �•\ ! , � ! � . . . �, �' �,'`.� `1 �, �'� �r `'�� �'f� - ' . . _ _��, , 1 �� � ''� . ;'�;-' . `� } i`, .. 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