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HomeMy WebLinkAbout1816A (10) WORKERS'COMPENSATION DECLARATION �6A� ,o�e, qpp�ICATI�N FOR ELECTRICAL PERMIT � I hereby affirm Ihat I have a certifimte of cansent fo self CE-806G insure,or.o cernficaie of Workers'Compensation Insuronte, COUNTY OF LOS ANGELES BUILOING AND SAFETY or a certified:to�py.��hereof(Sec.3800,Lob.C.) 7❑ol�icy No.�y�7v/�3�mpony�ND//S��jLL` FOR APPUCANT 70 HlL IN pDDRESS p{ D��� Ceriiiied copy is hereby furnished. .�/�� New Residen�iol Bld9s.8 Pyols Ee.CH NO. FEf 1 8 2-Fomil S FI. b� E — E LOCALIT +Z-� � Certiiied copy is filed with the covnry building inspec- Y� q� _ NeaaeSr . . � epar� ent � Multi�family Sq.Ft. fROSS ST. �/1 Residemiol Swimming Pools Ov.'NER OR Oaie —^' ApplitvN � FlRM NAME � � CERTIFICATE OF EREMPTION FROM WORKERS' _ Outlets:Rec—Light_Sw._ � ��� ��- COMPENSATION INSURANCE n�DRESS Firsr 20 C (Thi���etton na�d nof M complMed iF Ih�wo'k(nJolwd by Total No. Additional ��T� ��Tel.No. 7 y Ihe p�rmit Ic for on�hundr�d dol�on(3100)or los�,) , PV,N CHeCK �I certify ihat in Ihe performonce of�he work far whith this A7PlICANT _ permi��s iswed,1 shall not emptoy ony person in any monner - — so as ro betome subject to the Workers'Compensation laws. lighting Fiztures First 20 ADDRESS Toral No. AdditSonol CITY Tal.No. . Do+e Applitant Fiaed Applionces Nat Over 1 HP PEaMii i�j� f YE TO APPLICANT: I(, ofter moking�6is Certifimte of APPIICANT� � � E...,�ptlon, you shoold 6ecome subjecl fo the Workers' .Renge_Heater_D.W._ . Compensation provis�ons of ifie Lobot Cvde,you must forih. Oven _Dryer _W.M.— ADDRESS X ,� with comply with suth provisions or this permit shall be Top _FAU —W.H:— G deemed revoked. CITY � ' ���Tel.No.�'r y . Hood _Fan _Olher_ ^ LICENSED CONTRACTORS DEQARATION� uC�NSE OR �q/�p Closs �I ha.e6y affirm rhot I om Gcensed under provisions o(Chapter 9 � Disp. _Room Air Cond. — aEG.NUMBER (/L�O 4� � (commencing wirh Section 7000)of�ivision 3 oi�he Business DISTRICT NO. �� PR�D BY O}.' ond Professions Code,and my I�cense iz in full force and eHed. Power Apparaius 8 lorge Applianms t ,y�'�2 Size 8 Type HP,KW,KVA,or KVAR Q `6 �� V licema Nvmber �v V�" lit.Class C!� Up ro 1 IncL FINAL � DATE � .��1� VAUDATION � I�—' �f � (�� Over 1 to 101nc1. - U Confrado�`--���',� Oote s� Over lO fo 50 Ind. ❑ FINAL � W I am exempt under Sec. Over 50�0 700 Ina BY � B.SP.C.for this recson �ve��� �' '�`1 8 1.b A z � Date: ServiceS,Sw6d.,MCC 8 Panelboards � #• o o a .2 0-200 Amp.Under 600 V . . - SignpWre 201-1000 Amp.Under 600 V� I • 1 2 1,4 6 � Over 1000 Amp.or Over 600 V � Exemption(or Reg.Maint.EIecL � • � � ��.�l�J= SINGLE FAMILY Temp.Power Pole 8 Appurtenances � \ HOME OWNER-BWLDER DECLARATION $�9��rith One 9ranch C�rcoil O 9�2 G—c`�.o ,kby offirm�hat I am exempt from rhe Conrrac�or's Llcense qdditional Sign Branch Circuits ldw for Ihe following�eoson(Section 7031.5, Business a�d , Proiessions Code}: . - � ❑ 1,os owner of the properly,w�ll do ihe work ond the Misc Conduirs&Conduc�ors - ztrucfu�a is not iniended or oifered for sale(Settion Other(See Complefe Fee Schedule)_ , 7044,Businets ond P�afessions Code). CONSTRUCTION LEN�ING AGENCY I hereby nffirm ihal there is a con:truction lending egency for � � . . � ihe performance of the work for which this permit is issued PERMIT FEE - � (Sub-Total) �(� (Sec.3097.Civ.C.). . . � PLAN CHECKING FEE ' � . lender i Name - PERMIT ISSUING FEE � - lender's Address /�7/ i/ � I cerfiiy that I have read thiz oppfitotion ond s�ate�hat the TOTAL FEE d y - obove informolion is correct.I ogrea fo tomply wi�h all County ordinante5 ond Sla�e laws reguloling Eleclrlcoi wiring,ond . . � , hereby outhorize representatives of this County�o enicr opon th ve-mem�or+ed property for tnspecNor},pv�s� SEE REVERSE FOR E7(PLANATORY LANGUACE /�'j�� r� S�gnaWre et Permittee Dote ....., _-�'''� �: , , _ .'.. ;' ,� ;,�`: �` '� 1` !,,\ '`•° . ,;ti�f% ✓ ih' �,1 ;.'�, � � i ,f; . iy ` /ff ' `` ` 1 ) .., �" ,I` . ',_ .', , . .. \( �.� ,j `', �� . ' � ii.��� v-� l�� i� •! . - ' �i, ' �; .i" , `!* �i '��` i . - . . � ' j ' ,'a • . 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