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HomeMy WebLinkAbout1797A WORKERS'COMPENSATIONDECLARATION 16A683 /0/87 , /�ppLiCATION FOR ELECTRICAL PERMIT( 1� I here aftirm that 1 have a certificate of consent to self insure, CEBo6G � � or a etitieate'of Nbrkers'Compensatbn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETT `��� copy the/eof(Sec.3800.La6.C.) � . � PoIiCy NO���Comparry�NOvS7'K i� � FOR APPLICANT M Fl�L�N J06 .. �r/y �N��y� ��, PY �' New Residential Bldgs.8 Pool� Ao�fiESS 7 l �.-�c.�� ❑ .Certified co is here fumished . //VQ ?t/ EACH NO. FEE iv� Certified copy is tiled�With the county building inspection 1 8 2-Family,Sq.FL�sL.L_ � _ � LOCAUT 2 — G�'"�p? ' ��*� p rttn0 . Multi-f0mily Sq.Ft. NEAREST �3a S4� �oss ST. Date � � Applicant C Residential Swimming Poo�s pryNEq o�i , . . . .. . . FIRM NAM CERTIFICATE OF E%EMPTION FROM WORKERS' - - � � r.tAiL -�l COMPENSATION INSURANCE -- -.•� �utlets:Rec—Ught—Sw.— - � ADDRESS� , O� First 20 � (Thls seetbn need not be eompletetl If the work involved by the Total No. Additional - C N�� / �,Tel.N. permit ia for one hundred dollars($700)or leas.) - . I certify that in the perfamanee of the wo�k for which this permit . . ... vuN cHECK APPLICAM is issued,I sha�l not employ arry person in arry manner.so as to become subject to ihe Workers'Compensation Laws.. L'ghting Flx[ures Firs[20 ADDRESS - �- -� - — Additional �' � � � Total No. ' CITY' Tel.No. Date � �ADPlicant � Fxed Applianees Not Over 1 HP / . �E TO� APPLICANT:�If, a(Mr-makinq this Certifieate of PEAPPLICANT/��/ ption,you should become subiect M the Workers'Compensafron Range_Heater D.W. _ .prowsions of the labor Code,you must forthvrith eomply with such Oven— �ryer_W.M._ ADDRESS ,D � /f . - provisions or this permit shall be deemed revoked. . Top — FAU _ W.H._ - - - CITY �JV - � �7(��Tel.No.�Q�(,y�,� LICENSED CONTR4CTORS DECLARATION�� Hood_ Fan _Other_ � I here6y aflirm that 1 am licensed uMer provisions of Chapter 9 � Disp. — Room Air Cond. _ uCENSE OR //��p-3 C�i`r fo ' (commencing with Seetion 7000)of Division 3 of the Business and RE6.NUMBER� O Professions Code,and rtry license is in lull force and etfect. . .pow�r Apparatus 8 Large Appliances DISTRICT NO. PROCESSEO BY �}�,�'? Size 8 Type HP,KW,KVA,or KVAR I D ��d f1 Q �p L�ense Number "`�(J,-� Lic.Class C�U - Up to 1 IncL � - FlNAL - V -Contractor�✓�-���--�'�` Date `� r �r�������I� DA� �`� � VALIDATION 0 Over 70 to 50 Incl. FlNAL � F' ❑ I am exempt under Sec. Over 50 to 100 Ina gy . . . _. . W B.&P.C.for this reason Over 10D �` N _ _._ _ _ - �Services;Swbd.,MCC 8 Panelboards � � - � - � � Z �Date: - 0-200 Amp.Urder 800 V - - Signature 201-1000 Amp.Under 600 V ' � ��� �-�� �-" - - � � o��000 amp.o�o��soo v �1 7 9,7 A Ezemptbn for Reg.Maint Elect. _ . _ _ _ #• b • oe2 SINGLE FAMILY Temp.Power Poie&Appurtenances . . . . . � � HOME OWNER-BUILAER DECLARATION Sign wdh One Branch Circuit � � - �� � - --� - - J • � � �,g 6 �by affirm that I am ezempt fmm the Contractor's License Law .qddiCronal Sgn Brench Circuits r�.-. following reasOrl(Section 7031.5,Business and Professions �� �� _ codel: • • 1 1 S 2 6� ❑ I,as owner of the property,will do the work and the structure Misa Conduits 8 Conductors '� - � - � � O 9,2 2—H H . is not inlended or olfered frn sale(Section 7044,Business Other(See Complete Fee Schedule)_ ► and Professions Code). � CONSTRUCTION LENDING AGENCY � -� I here6y affirm thai there is a construction IeMirg agency for the performance of the work for which this permit is issued(Sec.3097, pEFiMR FEE � � (Sub-Totai) -� /(�5 � �� Civ.CJ. PLAN CHECKING FEE - - � - LendeYs Name PERMIT ISSUING FEE � � � - - � Lender's Address //� � I certify that I have 2ad this application and state that the above TOTAL FEE _... . intormation is corred.I agree to comply with all Counry ordinances and State laws regulating Electdcal wiring,and hereby authorize , . , ,_ _ . ._ _,_ _ _ represeMatives of this County to enter upon the ab ve•mentbned - proper fpr inspeCtipn pt�rppses. ��., � �/� � SEE REVERSE FOR EXPLANATORY LANGUAGE � V i?U L Si9nature of Permittee Date � ,`., � � , , - '% � . �, , - .�, : . . ' -`, , , i ;� .4 1. .. 'i � • �l. . j 7 'r. � �^�, •�. � � . ,,, '� � _ ,? . f i• � • , _ t � '\ , ' . �. r . . '�, ' ., �, , , . . . . . �f� , � '` � � ' -. , , �,r f � . : ,�..- '�.a .. , . '=� . . , , G �n .' . .�' �t, p p �-�p + , "" � � � Z Z N O b . , �� ;'-', I' a v �, m � �' � � � o ' �,. . m � ,< 9. N ;O t P p' � ', . 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