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 �
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