HomeMy WebLinkAbout1809A (10) I////(((-/�/�/�/''JJJ���''' /i
� WORKERS'COMPENSATION DECIARATION 76A663 ID/81 APPLICATION FOR ELECTRICAL PERMIT�
I here6y a((irm thai I have a certifitafe of consent to sel( CE-eo6G � �
inso�e,or a certificoie ot Workers'Compenzation Insurance, COUN7Y OF LOS ANGELES BUILDING AND SAFETY ��
or a certi(ied topy�hereof(Sec.3600,Lob.C.) �
P❑ol�icy No � � ompony/�Q�/.�Ty FOR APPUUNT TO Flll IN. JOB
Cerlif(ed m �s hereb furnished. � E �N NO. FEE ADDRESS � �
PY� Y /l/A, New Residentiol Bldgs.8 o Is� � S — 5 LOGAIITY
��y Certified[opy is iiled wiih the coumy building inspea �8 2-Fomily,Sq.Ft _
`�1 fi�� eport ent. Multi-family Sq.Ft. NEAREST
Residential Swimming Pools CROS55T.
Oota � Applitant OwNEROR
FIRM NAME
� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec__light_Sw._ � DDRESS �
COMVENSATION INSURANCE
� Tbif��etton nNd not 6�eem I�t�d 1I Ihe work involvad b Pirst 20 /�y
( P y Totol No. CIN " �(J Tel.No.
fh�p.rmif L for on�hundnd dollars(5100)or la�s.) Additional �'(- � �' !�//� �
I cerfify ihol in ihe per(ormonce of the wo�k for which this ppp���yry{� '
permit is issued,I shall nof employ any person in ony manner .
so as to become subjecf to the Workeri Compensation Laws. l�9hting Fixtures Firs1 20 ADDRE55
� � Additionol
Total No. CITY � Tel.No.
Date oPP�ican� � - Fixed Appliances Not Over I HP pERMiT /
i CE.t0 APPIICANT: If, after moking this Certi{imre of qP���M C
, �ption, you should become subjed 10 fhe Workers' Range._Heafer_�.W._ ;
Compensa�ion provisions of the Labor Code,you must forth- Oven _Dryer _W.M._ ACCRE55 ,� �/ �f//
.wi�b comply wi�h such provis�ons or this�permi�sholl be . Top _FAU --W.H.—
deemed revoked. � � � Hood _Fon _O�her_ CITY /�(,� ����� Tel.No. 9/Giy�
LICENSED CONTRACTORS DECLARATION Disp. _Room Air Cond. — - � uCENSE OR /1�7('� ��a_�y/
�hereby affirm thot I om licensed under provisions of Chapter 9 ReG.NUMBER �t/6 �ii r
(commencing wilh Settion 7000)of Division 3 of the Business DISTRICT NO. , PROCESSED BY � n-
and Professions Code,and my�icense is in(ull force and affett. PO`�'er Apparotus 8 Large Appliances �
C�/y��,()�Y� Size&Type HP,KW,KVA,or KVAR� 1 O �0.,1 O t� e V
License Number��J'��ILs.2_Lic.Class� Up to 1 Ind. F�NA� � p
�-y���l,� � Over I to 101nd. DATE �Z.l / VALIDATION �""
CoMrodor �/�_�-1��-1�-lT�Date Over 10 to SO lnd. Y V
O � FINAL . . W
I am exempt under Sec Over i0 10 100 Inc.- BY a-
6.8P.C.for this reason Over 100 � �
Z
�afe: Services,Swbd.,MCC 8 Ponelboords � �
0-�00 Amp.Under 600 V �� $�.��q
S�gnature 201-1000 Amp.Under 600 V �• • • ^ B 2
❑ Over 1000 Amp.or Over 600 V .
Exemption for Reg.Main�.EIecL � o �c���!b
SINGLE FAMILY Temp.Power Pole 8 Appvrtenances - �
HOME OWNER-BUILDER DECLARATION Sign wi+h One Branch Circoit • � C 1,Ll�c�
' �by affirm thot I am e:empt from the Controctor i license qdditional Stgn 8ronch Circuits� � - - � s �
low for.Ihe following reason(Seclion 7031.5, Business ond 0 9.2 2-fi 8
Professions Code):
❑ i,as owner of ihe properfy,will do the work end the Misa Conduih 8 ConduUon
strocfwe is not infended or offered fo�sole(Seclion Other(See Complete Fee Schedule)_ , �
7044,Business and Professions Code). .
CONSTRUCTION LENDING AGENCY
I hereby affirm thaf there is a construction lending agency for . . ,
rhe performance of the work for which fhis permil is issued PERMIT FEE - (Sub-To�ol)
(Sec.3097,Civ.C.).
. PLAN CNECKING FEE � �
tender's Name �
PERMIT ISSUING FEE - .
Lender's Address
I certiiy that I hove revd 7his opplicotion and s1a1e thal the T�TAL FEE � � � �
o6ove informoiion is covect I o9ree to compty with all Counry �
ordinontes and Sta�e laws reguloting Elecrrital wiring,and � �
here6y authorize�epresenfatives of�his Couniy to enter�pon
th bove-mentioned property for inspediq� rposes. . _ .
SEE REVERSE FOR EXPLANATORY LANGUAGE
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