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HomeMy WebLinkAbout1773A WORKERS'COMPENSATIONDECLARATION 78A663 +oiB+ qppLICATION FOR ELECTRICAL PERMIT �z . � I hereby atti�m lhat I have a certifcate of consent to self insure, CE-BO6G or a certificate of Workers'Compensatron Insurance,or a certiFied COUNTY OF LOS ANGELES BUILDING AND SAFE topy ther f� c.3800.Lab.C.) ��� Pol' N. � ���0�/"'/� iCy Cpfjlp� FOR APPLICANT TO fllL IN - J09 .:v�d ❑ CertiFied copy is hereby furnished. �� . New ResidenC�al Bldgs.8 Pool EACH NO.. EE._ ��ESS 8 /V/c.fc�/7 � � Certif'�filed with the county Wilding inspection 7&2•Family,Sq.FL� � — � LOCALIT �. �� �, � rt en Multi-family Sq.Ft. — NenReST . /yy� CROSS ST. Date � Applican ��/r Residentiai Swimming Pools OWNER OR - � . FIRM NAM N � �� . CERTIFICATE OF EXEMPTION FROM WORKERS� - \ � MAI� �. ? � Outlets Rec_L'ght_gw,— J � .COMPENSATIONINSURANCE � -� aooaeS (This seCtlon naed not 6e compleled I(the work imolved by the Frst 20 permit ie for one hundred dollars($100)or tass.) . Total No. Addilional CI N �70� Tel.No. 67 I certify that in the pertormance ot the work�for which this permit _ Pt-nr�cneCK � is issued,I shall not empioy arry per5on in ary manner 5o as to A�tCAM become subiect to the Workers'Compensation Laws. _, , L'ghtirg FixWres Frst 20 AODRESS � — ' - . Total No. A�iiionat CfTY � � Tel.N0. Date � •Applicant Fxed Appliances Nol Over 1 HP PERMIT i + NOTICE-TO APPLICANT: If,.after makinq this Cerlificate of AP��AM (` Q G Exemption,you shoultl 6ecome sublect to the Workers'Compensation Range_Heater_ D.W. , .pmvisions of,the La6or Code,you must forthwith compiy with such Oven_ �ryer_ W.M._ ADDRESS ,� � -�/�� - � ,provisions or this permit shall be deemed 2voked. ' Top _—FAU _ W.H._ _ _. - - � - CITY �^/v 9i7��Tel.No59�j LICENSED CONTRACTORS DECLARATION� Hood_Fan _ Olher_ . I.here6y,af(irm that I am licensed under provisions of Chapter 9 .Disp. —Room Air Corid.._ LIGENSE OR ��az � (commencirg wifh Sectian 7000)of Oivision 3 of the Business and REG.NUMBER ProfOSsions Code,end my licens0 is in 1u11 force and ef(ect. aSTRICT NO. PROCESSED BY � Power Apparetus 8 Large Appliances /`' �/1/� ���j��-� Size&Type HP,KW,KVA,or KVAR �v \�\ � 011 O � Lieense Number���Lic.C�ass � - UP to 1 IncL �� FINAL q JQ 9 . . .. U r�.��y��.�/ Over 7 to 10 Incl. �A�/4�Q/ VALIDArON � Contractor ���L1�L(�fl 1..� Date Over 10 to 50 Incl. U ❑ I am exempt under Sec. Over 50[0 100 Inc. FINAL � . . 6.8P.Q(or this reason Over 100 . BY �,` .. . . � , Services,Swhd.,MCC 8 Panelboards � �� � � - _ Z � � - �ate: - 0-200 Amp.Under 600 V Signature �- � -201-1000 Amp.Under 600 V -�� � -- � � � � � � � ❑-� - � � �� �� - � � �� Over 1000 Amp.or Over 800 V ?� 7�,J� . Exemption for Reg.Maint.Elect. , . , -� - �� �SINGLE FAMILY� �-� - Temp.Pov+er Po�e d Appurtenances �• e s • s'L HOME ONRJER-BUILDER DECLAflATION Sign with One Branch Circuit - � � � � � � �'�(a a 2 I hereby aflirm that I am exempt from the Contractor's L�ense Law a����al Sgn Branch Circuits for the following reason(Sec[ion 7031.5,Business and Rntessions � � coae�: • • +7 6�s 2� ❑ I,as owner of the pmperty,will do the xrork and the structure � Misa Conduits 8 Conductors - - - - � �9 2 2-�B Is not intended or ottered tor saie(SecYan 7044,Business Other(See Complete Fee Schedule)_ , - arM ProFessions Code). � � � � �- CONSTRUCTION LENDING AGENCY �� � -- � . . . _._ , I hereby atfirm that there is a construdion lendirg agency tor the � per(ormance of fhe work for which this permit is issued(Sec.3097,_.. .pERMR FEE� �--- � -�� ��� (Sub-To[al) .. Civ.C.). � �� . . . . PLAN CHECKING FEE . _ . _ . _ Lender's Name O � PERMR ISSUING FEE Lender's Address - � I certify that I have read this appiication and state ihat tFu3 above . TOTAL FEE �� � information is correct I agree to comply with a�l County ordinances . -- - - � . � - - and State laws regulating Elettrieal wiring,and hereby authorize . representatives of this County to enter upan the above-mentioned--� - � �"- � --" -- -� � - - - � proper (or inspec[ion purposes. � � SEE REVERSE FOR E7CPLANATORY LANGUAGE . _ _ . _ " /I"�r 2.� ��S Signa[u2 of Permittea Oa[e . , , : . - . . :..'.... . i_-�---- ; . � ; � , ' ; �� ,; • , , � ' � . �. . ' �: - _ � ` i j� ' � ' '� ' / � . - ` /� i,r, i ' ' / :i ,, ,�' r , , �r. i � . ' . . r . ' �� i,. � -- ' � � . t j .. ` . �. I ' ' � C -- . � � . . Z TZ �I p � i '37 C -1 • �, � D C z �� � .�c ZU � - , 4" , • �' r � � A � i � �. � . — i•� � O c N O � � � . . . '- v . ' j � ��'/ , z 2 � � .p� � �� O � � � � � � � � C Q 'D �D V . .. ' . 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