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HomeMy WebLinkAbout1772A WDRKERS'COMPENSATIONDECLARATION 7eA883 ���81 pppLICATION FOR ELECTRICAL PERMIT � � {� � I hereby aftirm that I have a certificate of consent to self insure, �E-BosG or a certificate of Workers'Cmripensaran tnsurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY - u copy the c.3800 La6.C.1 �j(� �;�. PofiCy N0. Compam//���V-���'�� FOR APPLICANT TO F7LL IN � ��B � z /7NT� �(/2. ❑ ,CertiFied eopy is hereby tumished. . �/��. New Residential Bldgs.&Pool��/�� �EACH NO. g _FEE ADORESS '�'�Cerfifietl eopy is filed�-with th county buildirg inspection 1&2-Family,Sq.Ft.�Z — LOCA � tme . - � ' _ MUIIFfamily Sq.FL NErwEST , Residential Swimming Poo�s CROSS Si. �ate � Applica owr�ER ort - � . FIRM NAME N ' �CERTIFICATE OF EXEMP710N FROM WORKERS' putlets Rec_,Light_Sw.��— MAi� � � � � � �COMPENSATION INSURANCE �+ � Flrst 20 - ADORESS� �(Thia sedion need not be eompleted if the work fnvolveU by the Total No. Additional CIT U�/Q �� Tel.No. , � permN(s lor ona hundred dollaro(5100)or lass.) ��I certity that in[he performance of ihe work for which lhis permit . , PtAN CHECK is�issued,I shall rrot empby arry person in arry manner so as to APPUCANT 6ecome subject to the Workers'Compensation Laws.. , . Lighting Fiztures Frst 20�- ADDRESS - — . . . . .. . � Additional - � � � - � � Total No. qTY Tel.No. Date Applicant NOTICE�TO APPl1CMJT: N, after making this��Certificate of Fxetl AOP���Ces Not Over 1 HP pEqMiT �i A• G•/`���G . �Exemptbn,you shouid become subject to ihe Workers Compensal'ron Range_Heater_ D.W. _ APFIJCarti (J�Z� provisions of the Labor Code,you must fortMwith comply with such Oven_�ryer_ W.M._ ADDRESS _D. ���� provisions or this permit shall be deemed rewked � Top _FAU _ W.H._ . �LICENSED CONTRACTORS DECLARATION Hood_Fan _ Other_ GTY � /,u Tel.N glG G I hereby affirm that I am Iicensed untler provisio�of Chapter 9 Olsp. _ROom Aif Cofd. _ LIGENSE OR C��/e (commencing with Section 7000)ot Drvision 3 of the Business and REG.NUMBER Rofessions Code,aM my license is in tutl foroe and effect. . power Apparatus 8 large Appliances�-- oiSiaiGr No. rROCyE}55�eo er` L'�/ Size&Type HP,KW,KVA,or KVAR � � \ '\0.\U 11^2 � License Number `� ���ic.Class � � ' � - - Up to�7 Incl.� � �� FlNAL 7X n9 � U . _�7�n..�J . Over 1 to 101nc1. DA�/ �/ `�/ VALIOATION . � ..ContraEtor�-�c.•� "1��1V Date �� - � OO Over 10 to 50 Incl. FlNAL�iJ .❑ I am exempt under Sec. �� - Over 50 to 100 Ix. gy �// U B.&P.C.for this reason Ovei 100 �`�6 �� d � .. . .... . . . . . . - Services.Swbd,MCC 8 Panelboards .. . . ,. .-.. . . . . . . . . Z Date: 0-200 Amp.Urder 600 V � Signature � 201-1000 Amp.Under 600 V� - � " - - � - ` � � � - - - - - Over 1000 Amp.or Over 600 V � ❑ EzempYwn Por Peg.Maint.Elect. - � - - �- � � �� 7 7.2� � �� � � SINGLE FAMILY �� .. Temp.Power Pde 8 Appurtenances �• � •2 HOME OWNER-BUIL�ER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractors License Law � . .'](�g 2 for the following reason(Sedion 7031.5,Business and Professions--- �Additional Sgn Branch Circvits -� � . - Codel: • e :7�l5�c=i ❑ I,as owner of the property,wili do the work and the structure Mise:Conduits&�Conductors�- �� �- � - - - - � is rwt intended or offered tor saie(Section 7044,Business other(See Compie�e Fee Schedu�el_ O 9.2 2—II 8 and Profess(ons Cotle). . . . . ... ,. .. . �. . . . . CONSTRUCTION LENDING AGENCY � � -- - - I hereby affirm tha[there is e construction lending agency}or the � perlormance of the work for which this permit is issued(Sec.3097, pERMR FEE � (Sub-To[ap � � Civ.C.�. ' PLAN CHECKING FEE � - � � � � Lender's Name �- PERMR ISSUING FEE � LeMe y Adtlress - . . . .. . . .. ^�' � . . 1 certif thaf I have read this application and state that the a6ove- �� TOTAL FEE � inlormation is correct.I agree to compiy with all County ordinances and State laws regulating Electrical wiring,and hereby au[horize _ . __ _ .. . , � representatives of this County to enter upon the above-mentioned . � - -- � � for inspection purposes. / _. ._.. - SEE REVERSE FOR EXPLANATORY LANGUAGE � - � C� 9�S/� Si9nature of Permittee Date . ... , - . I �.:�'..... . i....� - -i --- -.._ _i_ I._.. _ !, -- -- --�I - _ . ; e I . ! / �, i , . `� � j i � • , � ,t ��. ;, � � i 1i,.. ' i i/^e:;� � � � • - ;i .i � ,i . ' � ;J�, , . . � j` , � ' . i �. � � • . I i J• ��' . � t! i ' '�j; 1 � � ... . i- ..., . 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