HomeMy WebLinkAbout1776A (10) WORKER$'COMPENSATION DECLARATION �6A66� �Qie� qpp���ATION FOR ELECTRICAL PERMIT j�. ry�
I here6y affirm thot 1 hove a cer�ifita�e of consent to self CE�BfM�'
insure,or a certifimte of Workers'Compensalion Insurance, COUNTY OF LOS ANGELES BUILDING ANO SAPETY ��
ar a ce�tifi d c phy/I�he�reo7f(Sec.3800,La6.C.) � U
P�ol�icy N���yj;��Q�COmpany�yD[�S�/�TC� FOR APHICANi TO Flll IN� !OB
Cerfified copy is hereby furnished. �N.Q• New Residential Bldgs.8 P s EACH NO. FEE ADORESS � �N �'
� Cerfified copy is filed wirh�he county building inspeo- 1 8 2-Fomily,Sq.Ft. � a = S «ALIT a � �'�' � �
NEARE51
. lion epar ent. . � Muili•familySq.Fl. CROSSSi.
q r Residentiol Swimming Pools OWNER OR
Da1e Applicont . . f�RM NAM �O
CERTIPICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_light_Sw._ DDRESS •�, /
COMPENSATION INSURANCE Firit 20 p y
(Thi�iecllon na�d not b�complW�d I(fh�work Involvod by Total No. � Addilional �� /✓� j//(7�- Tel.No.�(p�9��
1h�p�rmit ts for on�hundrad dollars(;100)or I��s.) PIAN CHEIX - �
I terfify that in fhe pe�formante oi the work for whith this ` - APPIIUNT
_ permi�is issued,�sholl no�employ any persan In any monner -
so az to become subject to the Workeri Compensation lvws. ��ghling Fixlures First 2(1 ADDRE55
� � Toial No. Additionvl CITY Tel.No.
Da�e Applicanl Fixed Appliances Not Over 1 NP pERAAii ,i. ��7
710E TO APPLICANT: N, affer moking Ihis Cerlificafa of APPIICANT � c/Q7�� �
�Fnption, you should become subjecl �o the Workers' Ro�9e_Healer_D.W.—
Compensofion provisions of�he tobe�Code,yoo must forih- Oven _Dryer _W.M._ � ADDRESS �_ x ����
with mmply w'Ih svch provisions ar Ihis�permit shall be Top _FAU —W,H:—.
.deemed revoked. � - � CIN � �� �70� Tel.No. �� �/
� Hood _Fan _Other_
, �LICENSED CONTRACTORS DECIARATION UCENSE OR p�6 /�
I hereby affirm fhat I om licensed�nder provisions of Chapfe�9 Oisp. _Room Air Cond. — REG.NUMBER (!�/D C�OS3-`�Q r
(mmmencing wilh Sedion 7000)of Division 3 of�he Busmess DISTRICT NO. PROCESSED BY . p�' .
Power Apparotus 8 Large Appliances
ond Professiont Code,and my license is in full force and affect. - \ O�
2 Si=e 8 Type HP,KW,KVA,or KVAR- ` �I d�}�'e V
ticense Number ����J Lic,Closs�^ Q Up to 1 IncL FINAI �
�J , Over I to 10 Incl. DATE � (O � VALIDATION �.
Comroctor�_/� �-Do�e Over 10 to 50 Ind. V
❑ FINAL W
1 om ezempt under Sec Over 50 fo 100 Ine. BY ( ��
Over 100 ��
8.8P.C.for rhis reason • . Z
Date� Services,Swbd.,MCC&Panelboards - �
' 0-200 Amp.Under 600 V �� ']'](�n
Signature � 201-1000 Amp.Under 600 V
❑ � Over 1000 Amp.or Over 600 V . . �• • • • •2 ...
Exemplion for Reg.Maint.Elect.
� SINGLE FAMILY I • �7 Et II G
Temp.Powe�Pole 8 Appu�ienances �
�\ HOME OWNER-BUILDER DECLARATION Si n with One Branth Circvit _ . e e e'�' " " 2
4eby oflirm�ha�I om ezempt(rom the Conimctor's license 9 � - � -- - � � ���u?J �- ������
Low for ihe followin9 reoson(Sedion 7031.5, Business ond � �� Addi�ional Sign Branch Circui�s - �
Professions CodeJ: �9'2�-�'8
❑ I,as owner ot the property,will do ihe wo�k ond the M,sc.�Conduits 8 Conduttors .
strutture is not intended or offered(or sala(Section Othei(See Complele Fee Sthedule)_ , �
7044,Business and Professions Code�.
CONSTRUCTION IENDING AGENCY � .
I hereby offirm Iha�there is a construcrion lending ogency for
ihe performance of the work for which this permit is issued PERMIT FEE (S�b-Totol) �
(Sec.3097,Civ.C.). ,
PLAN CHECKING FEE - �
Lender's Nome
PERMIT I$$111NG FEE � � �
lender's Address �
I certify that I hove iead�his opplication and s�aie tha�the TOTAL FEE . . ��
above in(ormation is correct.I agree ro comply with oll Counry _
ordinonces and 51a1e laws regulaling EleUriml wiring,and . - �
hereb�authorize represen�aiives of�his Coonry to enter upon
� �ove-mentioned property for inspeclio o�boses. -
�r �/� � SEE REVERSE FOR EXPIANATORY LANGUAGE
-� Signature ef Perminee Date .
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