HomeMy WebLinkAbout1792A (10) 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
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