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HomeMy WebLinkAbout1792A WORKERS'COMPENSATIONDECIARATION 76Ayy3 �o�a, APPLICATION FOR ELECTRICAL PERMIT � I hereby alfirm Jhat I hove a certifita�e of consent�o self CE-BO6G insure,nr a ce��iHmre of Workers'Campensa�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified Ico y thpereoi(Set.3800,Lab.C.) P❑oi�icy No J O ompony�N�//5T1L1}YL_ FOR APYIICANT TO FIIL IN �OB �f Certified cOpy is hereby furnished. ��yO, New Residential Bldgs.8 oois EACN NO. FEE ADDRESS O�� ��, � Certified mpy is filed with the mumy 6uilding inspeo- 1 8 2-Fomily,$q.Ft. 9� E — E LOCALITY �L�� � �^ jq depar men. � ' Muhi-fomily Sq.R, — NEAREST n CRO55 5T. x� 7 ResideMial Swimmin Poais —� J �ate � Applicont 9 RMNAME /Y /v CERTIFICATE OF EXEMPTION FROM WORKERS' Outleis:Rec_Li9ht_Sw., � � '��� COMPENSATION INSURAN�E �� nooze55 . � Th(f��cNod ne�d�nof b�com ���ad it�h.wo.k fnvolv.d b Firat 20 ( P Y Totol No. Additiono� Cltt �„9 ,oa Tel.No.�6� the prrmk fs for on�hundrad de�lon(5100)or I�ss.) I certify ihal in�he perfoimance oi the work for which Ihis . qppNjrCqVi4pjK _ permit is iss�ed,I sholl not employ any person in any manner — so os lo become subj¢d fo the Workeri Compensation Lows. . � ��9hling Fixlures First 20 ADDRESS � � � Totol No. Additional CITY Tel.No. Date opplican� Fixed Appliaoces Not Over I HP pERMit L� � �TICE TO APPLICANT: If, afler making this Certificote of ApPLIUNT �� �� �C�LL'��L'JG mption, you shoutd betome su6ject to the Workeri Ra�9e_Heater_D.W._ Compenso�ion provisions of the Lobor Code,you must fo.th- Oven —Dryer _W.A1.- ADDRE55 � ���� :with comply with such provisions or this permil sholl be Top —FAU _W.H.— � deemed�evoked. �� Hood _Fan _Olher_ C�N , �/�/ ��0�Tel.No. �ij' UCENSED CONTRACTORS DECLARATION LICENSE OR I hereby oHirm Iho1�am litensed undar provisions of Chopler 9 Dizp. _Room Aii Cond. — REG.NUMBER Class.��Q r (commencinq wirh Seclion 7000)of Division 3 of the B�siness DISTRICT NO. � PROCESSED BY a Power Apparotus 8 Large Appliances and Professions Code, d my license is in full iorce and eHed. j� O� - Qj Size 8 Type NP,KW,KVA,or KVAR 1(� \O t1-'Q License Number ��=+`� Lic.Class �� Up 10 1 Ind. F�NA� � � Over 1 to 10 Incl. DATE L` ��l �y VAtIDAT10N � !- Conlractor������ Dote � C� Over lO to`A Ind. FINAL W � I om exempt under Sec� � Over SO to 100 Inc BY �!�� ✓ � 4- Over 100 V` � B.BP.C.for this reason Z - Dare:� � Servites,Swbd.,MCC 8 Ponelboords � . 0-200 Amp.Under 600 V , . s� 7 9'2� Signature 201-1000 Amp.Under 600 V $(• • o o .� ❑ Over 1000 Amp.or Over 600 V . � Exempfion for Reg.MaiM.Ele[t. � • �9 4 3 4 SINGLE FAMILY Temp.Power pole 8 Appwtenances l HOME OWNER-BUILDER DECLARATION Sign wilh One Branch Circuit � � •Q��iG� !re6y affirm rhot I am exempt from the ContraUor's License qdditional Sign Bronch Circoits L'ow for the following reason�Setlion 7031.5,Business and � O 9 2 2—B H Professions Code): _ , ❑ I,as owner of fhe property,will do�he work ond the Mfs[.Condui�s 8 CondvUors � � strocture iz noi Intended or oifered for sole(SeUion Orher(See Complele Fee Schedule)_ ► _ 7044,B�siness ond Professions Code). CONSTRUCTION LENDING AGENCY - � I hereby oifirm fhot fhere is a consfruction lending agency for � Ihe performance of Ihe work for which this permit is issued PERMIT FEE � (Sub-Toto�J � � (Sec.3097,Civ.C.). ' PLAN CHECKING FEE � � �� � ' � Lender's Nome `� � PERMIT ISSUING FEE � lender'i Address � - I certify thol I have read ihis application and sto�e that�he TOTAL fEE � �3 � above information is correct.I aqree fo tomply wilh all Cou�ty . ordinances and S�a�e laws regulating Eleclrical wi�ing,and . . - hereby aurhoNze represenrotives of lhis Counry to eme�upon thp,� e-mentioned property(or inspecfion rp es. . . �� ��S/,_, SEE REVEBSE FOR EXPLANATORY LANCUAGE ��� Signatu�e of Permiftee Date _ � _ . _ , . .... __/ . i- -�. _...__ . . .�` "% - IJ � �' r,,. ; � '' ��:�n,. ' � `�. ' '� �, � �' 'i �i, • 'I ��. 'r/, 1;'�: � t �' ;,�d , � ;1� r, ��'� ' ! ,/ '. � r; i ' . 1t' ` . `�_ �,� `� - � ,� I/ ' !,�r . ',�v". : ' . 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