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HomeMy WebLinkAbout1784A , WORKERS'COMPENSATIONDECLARATION 78Afi83 �o�e� qppLICATION FOR ELECTRICAL PERMITC� � I herehy aftirm that I have a ceriifica}e ot consent to seif Insure, CE-8o8G � or a eerti(ieate of'Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereo c.380D,Lab.C.) �/ d� PoliCy No. ompany�'"D�����J� FOR APPLICAM TO FILL IN J09 '!�/ � � ❑ Certified copy is hereby fumished. , ��� New Residential Bldgs.8 Pool �./� EAC . N0. . . FEE A�Ress y)� /�j� �. � Certified copy is filed with the-county lwiitling inspection 1&2-Family,Sq.Ft. �d%�f S — S LOCAUTY�j� �"'�... �C� Mu�tl•(dmily$Q.FL — NEAREST . �Date f7esidential Swimming Pools � COWNER oR Applican n�-.,, l ' FIRM NAME iriV CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec—L'ght_Sw.— �' ' �� ' - COMPENSATION INSURANCE � ���`� - AD�ftESS� (This section need not be completed if tAe work involvetl by the Frst 20 permlt Is lor one hundred dollars(5100)or lasa.) Total No. Additional CITV ��L Tel. _ / I certify that in the performance oi the work for whbh this permit P�+N CNECK \ Is(ssued,I shall not employ arry person in arry manner so as to AP��� become subject to the Nbrkers'Compensation Laws. , , L'ghting Fixtures Frst 20 A�DRESS-� � - — � - Additionai - . Total No. CRY � � � Tel.No. Date Appiicant Fixed Appliances Not Over 1 HP NOTICE�TO-APPLICANT: If, after making this Certificate ot PERMIT � q �� G . Ezemption,you should become sublecl to the Workers'CompensaYron Range_Heater D.W. AP��� - _provisions of the Lahor Code,you must forthwith comply wifh such Oven_Oryer_ W.M._ ADDRESS .�. �����- ---� provisions or this permit shall be deemed rewked. , Top, _FAU _ W.H._ � LICENSED CONTRACTORS DECLAf7ATION Hootl_Fan _Other_ �m /Nf�� J/7p� 7e1.No. �� �f I hereby aHirm that I am licensed under provisions of Chapter J LICENSE OR �? � �(commencing with Section 7DD0)of Division 3 of the Business and Disp. —Room Air Cond. _ REa.NUMBER QJ -� � -���s � -- R�OFe55ion5 Code,and rtry IicenSe is in full force and e}feCt � DISTL7IG�NO. PPOCESSED 9Y � Power Apparatus&Large Appiiances /� t C��/y.a�G Size&Type HP,KW,KVA,or KVAR ,� V �C71\p�'�Q � License Number !�vv/S� Lic.Class�Cj�v -- Up to 1 Incl. - - � FINAL � - �� � � rJ�Z _�J y�,- Ouer i to 10 incl. �ATE � ..Contractor G/ 71Lf CJf�Oa}e._(�� - pver 10 to 50 Incl. • VAUDATION O FlNAL U ❑ I am exempt under Sec. - . Over 50 to 100 Inc. gy W B.dP.C.for thls reason Over 100 N' Services,Swbd.,MCC 8 Panelboards -. - — -. � - . . . Z ��-�� - Oate: 0-200 Amp.Under 600 V �� '7 a(��'� ^ �� Signature 201-1000 Amp.Under 600 V - - - - - ❑ Exemptbn tor�Reg.Maint Elect. Over ta0o Amp.or Over 600 V � j{. . . . .2 � � - ��� SINGLE FAMILY - - � � Temp.Power Pole 8 Appurtenances � � �9��'3�" HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - - - . , 1 hereby affirtn that I am exempt from the Contractor's Licensa Law . '`�`�^�u� for ihe fol�owing reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits coae�: 0 9.2 2—fi 8 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits 8 Conductols - - . is not inteMed or offered(w sale(Section 7044,Business Other(See Complete Fee Schedule)_ ard Prolessions Code). -� � � " �� �� , � � CONSTRUCTION LENDING AGENCY - � -- - � � . . . I hereby alfirm that there is a construdion lending agency fa�the �� • ' performance of the work for which ihis permit is issued(Sec.3097, . pERMR FEE � � (Sub-Totai) . Civ.CJ. .PLAN CHECKWG FEE. . _ . . . . . . Lender's Name PERMIT ISSUING FEE (� � Lender's Address I certify that I have read this aDP�ication antl state that the above TOTAL FEE 9y�[ �informatbn Is correct.I agree to comply with all Counry orAinances � and State laws regulating Electrical wiring,and hereby atrthoriza 2presentatives of this Counry to enter upon the above-mentioned --�" �� � � � � ' �� - � � -- � - � �� - � � - - ` p for insPectlon purpos� ���� .. . ._ . . . . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date � _ , ,,' -. - - - - ` ` — _ _' _ .___ . _ ._ __ i ._I.r..i i ; , ; ' � s . � i: i I�`', I , � , ,I r �� f � �� � ,� _ - - , - 4 , ' �ci �/� ' � _ �, , + , ,� i , � ' , ,., ' �r _ _. 1'. .i�i� . . ... . . . f� � , • . _ � ' . : � ti . �. i . i'm � C � ,� '77 0 Z m ' t' %:u' � � a �., � _ � � � v � `— n � cmi� O � � � c i " ; O � ` , z W p i 0 - �' -. �i � , � a . . � O � D •_ -, .. . . . , . 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