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HomeMy WebLinkAbout1783A WOFKERS'COMPENSATIONDECLARATION CE-e06G '°'81 APPLICATION FOR ELECTRICAL PERMIT � JJJ'''III I hereby aftirm that I have a certificata ot consent to self insure, `7 ' or a ceHificata of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY � � copy thsre�(,�$ec�8�0 Lab.C.) �� L� � Policy No. ��o COmpZ QVS��� FOR APPLICANT TO FlLL IN ' JOB n'• � A�DRESS (j7� Certified eopy is hereby fumished. . , �N� New Residential Bldgs.8 Po�^� EACH NO. FEE � I� 1&2-Fami�y,Sq.Ft. m v � S — � LOCALITY�/`/` a�'� �' Certified copy is tited with the cwnty buiieing Inspection 4� ftm2[. - � �A Mulfi-f3fTily Sq.Ft. — NEAREST (�/-�d� Residentiai Swimming Pools CROSS ST. Date��O � Applican - ��✓��� � OwNEROR � � � � � . ' , . FIRM NAME . CERTIFlCATE OF EXEMPTION FROM WORKERS' p�tlets:Rec_L'ght_Sw.�— � Mai� X .� COMPENSATION INSURANCE . . � .. . ADDRESS .(Thls aeetbn need nol be eompleted if the work irnolved by the Flrst 20 ..permit is tor one hundred dollars($100)or less.) Total No. Additional CITY �, Tel. . 67 I certify that in the performance of the work br whkh.this permit PLnN CnECK , (s issued,I shall not empby any person in arry manner so as to AF'F'uCAM — become sublect to the Workers'Compensation Laws. . . L'ghting Fixtures Fre[20 -- ADDRESS- � � — .. � � . Additional � ' � . Total No. CITY � Tel.No. Date Applicant Fized Appliances Not Over 1 HP NOTICE TO APPLICANT:.If, after making this Certificate of PERMii / � Exemption,you should becoma su6ject to the Nlorkers'Compensation_. Range_Heater_D W. _ ��CA�'�T provisions of the Labor Cotle,you must brthwilh comp�y with such Oven_Dryer_ W.M. �_ - ADDRESS ,�_� � - provisions o(ihis permit shall be deemed rewked. ,� _ Top_— FAU _W.H._ CITY /NJ ��7v� Tel.No. LICENSED CONTRACTORS DECLARATION Hood_Fan _Other_ I hereby affirm�that I am licensed under provisions of Chapter 9 p L�CENSE OR ,q,�� ci�iy/O (commexirg with Section 7000)of Division 3 of the Business and � Dis. —Room Air Cond. _ REG.tiunneER (/�/ Z.. Rofessions Code,and my license is in tull toroe and eFfect.�- oisrnicr No. raoCESSED ev � Power Apparatus&La'ge Appliances ���,,,''''''1 License Number /l/�D_'S Lic.Class C�U Size 8 Type HP,KW,KVA,or KVAR � � � A � Up to 1 InCI. FINAL n �) ��,/ � Over 1 to 101nc1. DATE/��/X �. Contracta f'�/�7��Gf7l-Date� � ' � p�r 10 to 50 Incl. - u� VALIDATION 0 ❑ I am ezempt under Sec. Over 50 to t001nc. gyA�r��y//L 1'1� _ W . . ... _ Over 700 '(/WC p,. 8&P,C.for ihis reason Services,Swbd.,MCC&Parmlboards � �� � � - - - . - N Date: z 0-200 Amp.Under 600 V s�9nacu.e 2oi-�000 ama.w,de�soo v - z 1 7$�A � --� - � � � � Over 7000 Amp.or Over 600 V Exemption for Reg.Maint.Elett. . �� • e s •�'� �� � - - -� �� .-� SINGLE FAMILY �� - � � Temp.Povrer Pole&Apportenances � HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ' � �- � • °9 G.3 4 I hereby a8irm that I am exempt from the Contradoi s License Law Mr ihe followirg reason(Section 7031.5,Business arW Profeesions - Additional Sgn Branch Circuits _ _ . •.s c G(,�(;,� Code): � MiS�.co�a��ts s co�� 0 9•2 2-8 8 ❑ I,as avner of the properry,wilt do the vrork and the structure � � is not interded or offerea for sale(Sectbn 7044,Business Ofher(See Complete Fee Schedule)_ ► and Professbns Code). �---- -- --- � - - - � -� - CONSTRUCTION LENDING AGENCY - .- ---- - I here6y affirm that there is a construction lending agency for the � performance of the xrork for which this permit is issued(Sec.3097,_. .pERMIT FEE � � - � -� - - _ (Su6-Total) . Civ.C.). � -� - - ..... .PLAN CHECKING FEE. _. Lender's Name //, PERMR ISSUING FEE V Lender's Address - � � I certify that I have read this application and state that ihe above TOTAL FEE �,3 information is correet.I agree to comply with alt Counry wdinances � � - - � �� and State laws regutating Electricat wiring,and hereby authorize representatives of this County to enter upon the above-mentioned -' � -� -�- - --� --- - � � prope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �2����- �/�� Signature of Permitlee Date .. ,: . . , �--- - . . . r . ..._ ... . . � __.__ j r I � � � - ' � �I I' .. � �.� �� , . �� . .. �./ � . 1 �' . i\ 1 �, � .; � ' � ; I i i , , %-. { , I - ,. . 4 .' i � " z Z S � -n "r O c m' ,.. . '` ' '. ,i N � -Ci m' c z � m v % ` � ' , � �. m � � t�n � � .... a � N o. y � � - � ^ •Z � m o. .` � • � � O o c � �' D � _ � � i � o � N � � �, m m m v, ; _ .;' - h � 4 � � � , ., .. . 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