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HomeMy WebLinkAbout1779A WORKERS'COMPENSATIONDECLARATION 76A863 +0�8, qppLICATiON FOR ELECTRICAL PERMIT � . � i here6y aifirm that I have a certificate ot consent to 5eH Insure, CE-eo6G �� or a certificate�of Workers'CompensaYan Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy th�:e f a 3800.Leb.G) Po,;�No. �36 (�,pm����V ✓� FOR APPLICANT TO FlLL IN JOB � Certified copy is here6y furnished. . �, �� • � New Residentiat Bidgs.8 Poo!I�c'�_ EAC N0. FEE aooaess � N �/L� D _rd� - 7&2-Family,Sq.FL J1�. `� = S LOCA� / �� � Certified copy is fled with the ounty buildirg inspection LJ rt t. � � � ` - � � � � Mul�l•fdmily Sq.Ft. - NEAREST CROSS ST. .Date� �Appiican Residentlal Swimming Poois , � � � pyy�q pq . . . . , . FlRM NAME �� - � CEF7TIFICATE OF EXEMPTION FROM WORKERS'�� . � p�tlets:Ree—L'ght_Sw.-= ^— �'� � �� �� ' Ma�� (>���( �_�9 � �COMPENSATION INSURANCE � �- �� � nooaeSS (Thls seetbn naed not be completed N the work Involved by the First 20 CIT � Tel.No. �9S� . parmit is tor one hundred dollars(SiDO)or Iess.) , Total No. Additional N �- 6 � PLAN CHECK �.I ce�tity that in the perfamsnce oi the work tor which this Dermit - - � � - pPp��qM � is issued,I shall not empby arry person in arry manner�so as ro . . become subject to the Workers'Compensation Laws. Lightirg Fizlures Frst 20� ADDRESS — - � � '� � ' �' Total No. Additronal qTY Tel.No. Date � Applicant ��- � - Fxed ADP��ances Not Over 1 HP per�Mir NOTICE TO APPLJCANT:.If, after making this Certificate of App���M// � . �Exemptbn,you should become su6ject to tha Workers'Compensation�. Rarge_Heater_D.W. _ �• provisions of ihe Laba Code,you must forthwith comply wi[h such Oven_Dryer_W.M._ ADDRESS ,�_ �X`�� . �provisions or this permit shall he deemed rewked. . Top _FAU� _�W.H._ � - CRY ��� ��� �Tel.No��j � - LICENSED CAN7RACTORS DECLARATION �� Hood— Fan _Other_ I hereby�altirm�that I am licensed uMer provisions of Chapter 9. Dis —Room Air Cond. — uGeNSE Oa . _ �� /r��7 (commerieing with Section 7000)of Division 3 01 the&isiness and p� REG.NUM6ER aL (/ Protessions Code,and rtry license is in fuil force and effect, oisiRicr No. PROCEsseo ev � Power Apparatus&Laige ApplianCes . . . . . . a Size 8 Type HP,KW,KUA,or KUAR 1 D � ����e O License Number Lb.Class � � ��� Up to 1 Irxl. � � � FINAL J �j U �7 .. .� pver 1 to 101nd. OA�/�/ �(J� VALIDATION . Q Contractor G/�2�-/C� �—Date Over 70 to 50 Incl. FINAL V . ❑,_I am exempt under Sec. -- Over 50 to 100 Inc. BY �/1��Z. .-.. . . . �W Over 100 6.8P.C.tor this reason � � . _ , _ Services,Swbd.,MCC 8 Panelboards - � ► - -�-� � - � � � �� � z --Date: � 0-2D0 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V � � - � - -� � - � � �1�7 7��� ❑ � - Over 7000 Amp.or Over 600 V {{• • • . •� Exemption for Reg.Maint E�eet. � - --__ _. . I a •81.94 �- $INGLE FAMILY � TemR�r.Poie 8 AppurtenanCes . . . . HOME OWNER-BUILDER�ECLARATION Sign with One Branch Ci¢uit � I hemby affirm that 1 am exempt 6om the ContraCta's L�ensa Law • °��� >4� for the followirg reason(Section 7031.5,Business and Protessions� Additional Sgn Brench Circuits • � code): 0 9.2 2—8 S ❑ Misc.Conduits 8 Conductors � � �� I,as owner of the property,will do the vrork and ihe stmcture is not intentled or otfe2d tor sate(Section 7044,Business.. aher(See Complete Fee Schedule)_ , and Pmfessions Code). CONSTRUCiION LENDING AGENCY " --� -- -- - - - � I hereby a((irm that there is a construction lendirg agency tor the perlormance of the work for which this permit is issueA(Sea 3097,� pERMR FEE � � (Su6-Total) - �� - - ��� - -- �-- �- CiV.G�. PLAN CHECKING FEE � � � � - - -�� - �� - Lender's Name � PERMIT ISSUING FEE � � U -� � - � Lender's Address �/ � I eertify that I have read this application and state that the a6ove TOTAL FEE . . . . . . . . .. _ _. . . intormation is correct.I agree to comply with all County adinances and State laws regulating Electrical wiring,and hereby authonze . . . - _ . . . . representatives ot this County M enter upon the above-mentioned c�p y fOr inSpeCtion purposes. SEE REVERSE FOR EXPLANA70RY LANGUAGE � !�.?-`_7��� 9/s� _ _ Signature of Permittee Date � ....+' " ~//��\.,` �y, ' '�'' ',��!_, . ; ',` ..�!l , j ',('/ �,1 _ � �. 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