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HomeMy WebLinkAbout1788A (10) WORKERS'COMPENSATION�ECLARATION 76A863 �o�e� ,qppLICATION FOR ELECTRICAL PERMIT�� I hereby affirm that I have a certificate oi consent to selt ins�re, CE-806c � or a certiticate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFET�f-- copy iheie (Sec.3800.Lab.CJ Po�icy No. %6�3 Comparry IN�U�'/�� FOH APPLICANT TO flLL IN �B DDRESS � �� � /N� EAGH NO. EE - .Certified copy is hereby turnished. New Residential Bidqs.8 Pao � _ S LOCALfTY�� � � '�=1 Cer if'ied'copy is filed with t aunty buiidirg inspection 1&2-Family,Sq.FL _ '�C 2fffI1Py MUlti-}dmily Sq.F�. NEAREST (�.{/'/ CROS$ST. Date o� ' Appiica Residentiai Swimming Pools - owNER oR . . . . FttiM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS':� putlets:Rec_Light—Sw.�— � ��� � � COMPENSATION INSURANCE - � � � aooaESS .�. � (This seetlon need not be completed if the work involved by the ���20 �� a, 7 95 permit Is for ona huntlred Ao�lars(5100)or less.) . Total No. Additional -_ ��T Tel.No. I tertify that in the pertormance ol the vrork for which this permit � . pp�i�N7 H- � is issued,I shall not empbY�Y Person in am/manner so as to _ 6ecome subject to tha Workers'Compensation Laws. - L'ghting Fixtures Frst 20 ADORESS �� . ' . Total No. Additional ��y Tel.No. � � �ate Applicant Fxed Appliances Not Over 1 HP peaMir /� i ��i�' � ,,T'"� E TO APPLICANT: If, after makirg this Cedificate of APRICANT C G�/wG � . r�Fron,you should become subject to the Workers'Compensafron Range_Heater_D.W. _ . provisions o1 the Labor Cotle,you mus[forthwith comply with such Oven_Oryer_W.M._ ADDRE � � . provisions or this permit shali be deemed rewked. � . _ __Top__FAU _W.H._ - � CITY ��,9 �� Tel.N��� LICENSED CON'fR4CTORS DECIARATION .� Hootl_ Fan _Other_ � ' � I hereby affirm that I am licensed under provisions o1 Chapter 9 . Dis —Room Air Cond. _ uceNse oR � . _ Cia�� (GOmmenciry wi[h Section 7000�01 Division 3 of the Business and p� REG.NUNBER Protessions Code,and my license is in full force arid eifect. � Power Apparatus&Large Appliances DISTRICT NO. PROCESSEO BY � License Number v V� Lic.Class` �� _ Size 8 Type HP,KW,KUA,or KVAR l.J �\O � - �Up to 1 hicl.� � FlNAL - V Contractor�=���`f� `-� Date -�� . �r 1 to 10lncl. �A� �—(''. VAUDATION _ 0 � Over 10 to 50 Incl. flNAL �j ❑ I am exempt urider Sec. _ Over 50 to 100 Inc. BV . B.BP.C.for ihis reason Over 100 �' - Services,Swbd.,MCC 8 Panelboards - �� � � � Z ...- ..- . . . Date: 0-200 Amp.Under 600 V st9nat�re 20�-�o0o Amp.u�ae�soo v - �1 7 8.8 A � �- � -� � - �---�- � � Over 1000 Amp.or Over 600 V � Ezemptbn for Reg.Malnt Elect. �- - � �° � � � �� � ��� � SINGLE FAMILY - � Temp.Power Pole&Appurtenances � o b 9 Q,j[G l� HOME OWNER-BUILDER DECLARATION � Sign with One Branch Circuit ' �y aflirm ihat I am ezempt from the Contrector's License Law p�itional Sgn Branch Circuits ' ' ' '�/�� `���-� h,._�Se following reason(Section 7031.5,Busirress and Rofessions � � - - - � Code): �G.2 2—8 a ❑ I,as owner of tha Oroperry,will tlo the work and the structure Misa Conduits&Corductors-- - - � � - , , is not intended or olfered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ , ana Protessions Code). CONSTAUCTION LENDING AGENCY � � � � � I hereby affirm that there is a construcfion IeMing agency for the - performanee of the work for whlch lhis permit is issued(Sec.3097, pERMR FEE -- � (Sub-Total) - - � - �� � � - � � � Civ.Q�. . PLAN CHECKING FEE ... . . - . - . LeMer's Name /j� PERMIT ISSUING FEE U Lender's Address Q �� I certify that I hava read this aDDlication and state that tha a6ove 7YlTAL FEE / _ � � information is corred.I agree to comply with alt County ordinances and Stata laws regulatirg Electr�al wiring,and hereby authonze � representatives of this County to enter upon the above-mentioned �� -- - - - - - � � prope lor inspection purpose� ��� SEE REVERSE FOR EXPLANATORY LANGUAGE . . . . __ _ . . _. � �� Signature of Permittee Date ,. . . . . . ,- ---, . . _.. .. __.. . . . . ,.._ .... _. , E� ' ( ; ; ; f . . it , , , . . , ! r �'- � I/ . . F' I r ! i ' A, � � , � . �� j� ,t i,� ;' _. 1 .'�!I ' � l:�, * " /� �i i ' % , . �_ , .. _., �. 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