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HomeMy WebLinkAbout1777A WORKERS'COMPENSATION DECLARATION 76A883 10/87 qppLICATION FOR ELECTRICAL PERMIT �"� I hereby affirm that I have a certificate of consent to self insure, CE-BosG � or a certiticate of Workers'Compensatron Insurance,or a certifietl COUNTY OF LOS ANGELES BUILDING AND SAFETY copy there ( 3800.Lab.G) Policy N0.��mPan�N C� L FOR APPUCANT 70 FlLL IN. � .._ .. _. . JOB- /' :❑ .Certified copy is hereby fumished. . aoDrtess(Q�a' fj.� . .- .� ,,,�. ' . New Resldentiat 81dgs.d Po s ���CH NO. _.. FEE.. . -�� 7 8 2•Fami� LOCALITY� Certilied�copy is filed�with ihe� ounty'huilding inspection Y,Sa�Ft. S — g OT rtmen . �. - Multi-fami�y Sq.FL — NEnnESi _ Residentiai Swimming Poois C(70SS ST.���� �3t0 AppiiCan . ' O'NNER OR `, . . . . . . '• . ._ _ _, . FlRM NAME � . -�GERTIFICATE OF EXEMPTION FROM WORKERS'-� � - _�?�� � nui� � � �COMPENSAiION WSURANCE � ',, . ��ts Rec_L'ght—Sw.— �\ �� „ . . . pppqEss JC �(This eectbn r»ed nM 6e completed R the work InVolved by the � Frst 20� ,.permit Ia for one hundred dollars(S 100�or less.) . . Totai No. Additional.�- - _ GT ��,Q 9i�oa Tel.No.9 7�'/.1 I certiry that in the peAormante of the work for whkh ihis permit . . . _ _. P�AN cneCR_ - � ;� Is tssued,I Shall.rrot emp�oy ary person In any mannef so as to ��. APPLiCAM _ become subject to the Workers Compensation Laws. �� L'ghting Fixtures Flrst 20'� � - � �� �-�- � ADDRESS ��- - -� --�-- � . .- -- . . - . . � . Total No. �ditronal �CITY-.- . - ... -. Tel.No. �Date Applicant � Fixed Applia�es Not Over 1 HP � .NOTICE ,TO APPLICANT: If, after making�this Certificate of . PeaMIT � �nq Z/ G �Exemplion,you should become subject to the Workers Compensation Rarge_ Healei_D.W. _ Ar��� /�' � provisions ot the Labo[Code, � must torthwith tan I with such � Ovzn � � � ADDRE55-- � � � - , YW PY _ DrYer_W.M.— .�.. h/ ._ ��.. __._...__ .provisions or this permit shan be tleemed rewked. �, - ___._Top_._.FAU _ NJ.H.__. ^y . _ ..�. .__ ... . _ . . --� CITY .' � .. � (!O -Te1.No. f/�j� LICENSED CONTRACTORS DECLARATION Hood_ Fan _Olhei_ .I hereby affirm that I am�icensed under provisions�of Chapter 9_._.. ._Disp. — Room Air Gond. -- uCENSE oR � . .._.._..CiassC�Q (commencirg wRh Section 7000)ot Division 3 ot the Business and FEG.NUnneER . Professions Code;and my license is in fuV torce and elfect. oismici No. aeocesseo sv � _Power Apparatus 8 Large Appliances . _. �n _ ._ . .. . . .. ___ l`\a�`011_ .__ � Size&Type HP,KW KVA or KUAR _._... .. . .._. ._.._. ...__ . . _ License Number__�Lic.Class�� .... _.-... . .. Ua to 1 Incl. .. _._ . .. . ._ _. DIATE/.��/ VAUDATION � � Contractor`����!!�� �Oate� -. Over 1 to 701nci � . � . _ . . . ... . ..__ ._. _. ._._ -... Over 10 to 50 Incl. FlNAL L ❑ I am exempt under Sea . -.- .. ,_ .___ O�er 50 to 700 Inc. , � gy__ J � � __ W _. _. __ _ . . __.__. B.&P.C.for Ihis reason Over 100 l - N' ._ .Services�Swbd,MCC&Pa�lboards.._ .._.._.. ._.. _. .� ..... _ ._ .. .... .. . . ....... _..__ Z -'-...__.__ _ ._. ... -Date:-- -- . � 0-200 Amp.Under 600 V � � Siqnature �-� -��201-�1000 Amp.Under 600 V.- --. -- . - -- -.. . . . . . . . .- .. . . � --- o�e�1000 Amp.or Over 600 V :� 7 7.7 A ... .___ .._._ .. . � ExemPtion for Reg.MainL Elect. .._ _.- p. . .. _...... . ...._ . . __ . . .__.. . . .__... . . _ . _ -— ye . . : .2 --� --� � �'-���- � 'SINGLE FAMILY'-'�""�-' �� '�� Tem Power Po!e 8 Appurtenances HOME OWNER-BUIL�ER DECLARATION -- - - "�� �-- -�� " � " '-- � ����- �- �-�-- ' - - - _._ Sign with One&anch Circuit � . �' '�,9(R I hereby a(ftm that I am exemp[from ihe Contractor's License Law Atlditional Sign Branch Circuits ,- - - � � � tor t�e following reason(Section 7031.5,Business arW Protessions � � - - - - - �- ----��-�--- -�- - �- . � Code): e o e-c I,�'Yl� - - Misc.Conduits 8 Condudors-- �� � ----- - -�� � � ❑ I.as owner of the -" 0 9.�'2—8 8. proper}y,wiil do the vrork aM ihe structure p�her See Com I is not In[endea or oflered for sale(Section 7044,Business ( pete Fee Schedule)_ and Professbns Codel. - ------. __-. . ... _ . . . _ _.._. . ... _._ . . CANSiRUCTION LENDING AGENCY �-- --- -� - • �-� � �- � - - - - �- - -- -. . . __ __.. _ . ..-- �----- I hereby aHirm ihat ihere is a construdion lending agency(or ihe ' performance o1 the vrork for whieh this permit is issued(Sec.3097, ... .pERM1T FEE�� --� -- -- � -�� �����-(Sub-Total)�- ��-'� - � � Civ.C.1. ._.. .. _ _ . . ... . .. PLAN CHECKING FEE . _ ....__...__...._ . � _ . . . __. _ .. ... .. _ .. _..._._ ._ . _ Lenders Name , � _,_ pERMT ISSUMG FEE._._, _ ..�._/�_ _ . . _. . ..__'._.._ .. . ... __. ... _.. .._...__ �__._ _. Lender's Add2ss -- ��.�. . I certiry that I have read ihis aOP��tion ard state that the above TOTAL FEE � � � ..__ _.__... ...---_... .. .---.. . ___ ._.. _... Information is correct.I agree to comply with all Counry ordinances � � � and State laws regulating Electrical wiring,and here6y aWMrize � . . ; i 2Presentatives W this Counry to enier upon the ahove-mentioned-�- �------....." .-...-..._._. .._._ ..__. _.. .._. . _ ._. _. .... . . _ ._ .. . . ._...___._.... ........._.._...._. prop�ct9�fw inspection purposes. �/��� . . SEE REVERSE FOR EXPLANATORY LANGUAGE. i ...._ .. . _.. . _. ..� .--� -- ..._ ...__..._...___ . .�/yI�_Pp. Signature of Permittea Date ' . , � _ , i . , � a:�.'.t��\:��i�T ..r�. . � �, � �—� � r-' — I � i ( �` ;J-. �I_' 'i�� � 1 � � - l I ,f.-� � ' i i � � � I �.�; � j . . �� 4'��` ,� I /�'II 1 I_ ' I� /j .. ,. .. � �y - 1 I 1 �i i%1 , � `�' . 4! I�; I i .� �� � ��I� � r - �F' .� �'� � 1�: I I 1 �.j j; 'l i/�� ' c.: I � � i I/`'�, f 1 � . I� -S � - �� M�n, � � i - �. ' � y' ' , , .� � - � ., .. �•._ � ; j;/ �i � , f � � C••. I j ,•. 'J -i i -,� i'^ ;l i� ' ( � �� / i �' �,/�i�; i t , � � - i-- -i — i- �. 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