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HomeMy WebLinkAbout1786A (10) `ERS'COMPENSATION DECLARATION 78A663 +o�B+ qppLICATION FOR ELECTRICAL PERMI�� � I here. �S I h�a certificate of consent to se�f insure, CE-e06G or a ee. �Vorkers Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUIL�ING AND SAF TY copy lhe,.:�[(S'�ec�.y38J0�0,�L9ab.CJ , Policy No����1��omPyryl/VDI/STfL�/J�'C� FOfl APPLlCANT TO FlLL M . . . JOB ❑ Certified copy is here6y furnished ... ��� New Residential Bldgs.&Poo�l ��(�� EACH NO. EE . '�DRE55 � �T X �Cehilled copy(s filed with the couoty buiidirg inspection 1&2-Family,Sq.FL�dY� $ _ � LOCA �L� / /3 � Date��pdep�✓hn'�ent • A �y�/" Mufti-family Sp.Ft. NEnaEsr . ; /,�/ � � ��� r�/J'��! /�/�� ReSidential Swimming Pools CROSS ST. ��. Applican�/`*��`^ /� '•/�/�� OWNER OR - � . _ ._ . FIRM NAM N . �CERTiFICATE OF EXEMPTION FROM WORKERS'�� Outleis:Rec—Light_Sw.—�''����r,-� � � ��� ,(�•�.,,xJX � CAMPENSATION INSURANCE � � - � ADOReSS �(This aectbn need�rot be aompleled H the wark Involved 6y the Frst 20 permil Is for one hundred dollarc($100)or less.). . . Total No. Additional �� CIT ��/� ���], Tet.No. 7��� I certiTy that in the pertorma�e o(the work fo�wh{ch this pe�mit ; . . ___ _ PLAN CMECK APPLICANT is issued,I shall rmt employ arcy person in airy manner so as to - become su6ject to the Workers'Compensation laws. , L'ghtirg Fixtures Frst 20�-- - ADORESS - . . -- Addilional �� �- ' � Total No. �- CRY � �' ' Tel.No. Date � � � Applieant � � '� Fxed Appliances Not Over 1 HP � NOTICE TO APPLJCANT: If, after making- this Certificate oi AEPPLICANT ���/ r — L� Exemption,you should become subjeCt to the NPorkers'Compensafan. Rarge_Heater_D.W. _ �provisions oi ihe La6or Code,you must forthwith compty with such Oven_ Dryer_W.M._ ADORESS .D, .x /� , provisions oLICENS D'COaINTRACTO S D CLA ATION �� Top.. _-FAU ._W.H._ �Ry �jN� � ���' TeI.No����j/ Hood_Fan _Other_ � I here6y affirm that I am iicensed uMer provisions of Chapter 9 - Disp.-_Room Air Cord. _ uGeNSE oH �� , (commencirg with SecNon 7000)of Division 3 ot the Business and AEG.NUMBER �a�� �� � Professions Code,and my license is in Full face and effect. . . power ApOaratus 8 Large Appiiances , . oisiRiCi No. PROCESSED BY } n'.�� C/� Size&Type HP,KW,KVA,or KVAR � r'f�Q`p� �' + Ucense Number !Ti/ �.Class . .. . -�- UP ta t IncL ... - . . -. . . FINAL/���n � � �/�C-�//c-(Nf'L--=. . .� . . DATE � / Over 1 to 101nc1. VAUDATION Contract Date OO � Over 10 ro 50 Incl. FINAL �/ ._❑ I am eu�empt untler Sec. - � Over 50 to 100 Inc. . gy /�` . .. ... w B.RP.C.for this reason Over 100 � N _ sery�es.sWba..Mcc a Pa�rooarag _ ` _ �1 7&6 A z � - ��ate:- � 0-200 Amp.Under 600 V Signature � - 201-1000 Amp.Under 600 V � � � �- � �� �. • • • •2 O - - -� Over t000 Amp.or Over so0 V . . . . _ . .._. � � �� 9(,�v 4 Exemption for Reg.Maint.Elect. � � i z � � � � -- -SINGLE FAMILY � Temp.Power Pole&Appurtenances � HOME OWNER-BUILDER OECLARATION � -- ° ' "9 1������% . I hereby aFlirm that I am exempt from ttre Contractor's License Law Sign with One&anch Cirouit tor the following reason(Section 7031.5,8usiness and Professions �ditiona�Sgn erench Circvits - . . _ 0 9 2 2_�j� Code): . ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors � - ' . � -- - is not intended or offered for sale(Section 7044,Business._ Other(See Complete Fee Schedule)_ ► and Professions Code). CONSTRUCTION LENDING AGENCY - - � � � � � -� I hereby atfirm that there is a constmction lending agency for the � performance of the work tor which this permR is issued(Sec.3097, pERMiT FEE- � � � � � (Su6•Total) �� - - � �- � -� Civ.CJ. - PLAN CHECKING FEE - - � � � � � - � � . . .. Lender's Name � PERMfT-ISSUING FEE .� Lender's Address � I certify tha[I have read this application and state thaf the above . TOTAL FEE . . . . .. , _ informatbn is correct I agree to comply vri[h all County ordinances � and State laws regulating Elechical wiring,and hereby authorize _ , _ _ . _, . representatives of this County to enier upon the above-mentioned � � � � � � - � � p for insPectio��e� �/� � ... _ . . . .. ._.. . . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Oate � .� .. _ .. _ . i', i '-.� . - �^ . .. . _..��,J - -'.. ._ _ _ _..__... - - --i---.i._._I _. ._ j i �� i � ! ; ' � • ' � ;:� _ � . , -,^ - . , i l .tr�. � I �. ' i � ,I , ; I' i � i , . 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