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Home My WebLink About1780A (10) WORKERS'COMPENSATIONDECLARATION 76a663 i0ie� APPLICATIQN FOR ELECTRICAL PERMI�` /� I hereby offirm�hot 1 hove a certificate of consent to self CE-BO6C � insure,or a cert�f�mte of Workers'Compensmion Insurance, • COUNTY OF LOS ANGELES BUILDING AND SAFETY` ar a certiiied co y thereof(Sec.3800,Lob.C.� �A - P�olicy No.��7etompony��dUS�/lTG� FOR APPLICANT i0 FlLL IN DDRE55 l � /�, Certified mpy.is hereby(urnished. �~i�. New Residential Bidgs.&poq�s�,.. EnCH NO. FEE � � I$2-Fomil q, l! _ — E LOCALITY � �' Cerfi(ied copy is filed with the coun�y building inspea y,S FL�— eporimenl. -� Nolti-fom�ly Sq.R. NEAREST � �+�� CRO55 5T. Dole �r� qppiiconl � ResideMial Swimming Pools � OWNER OR flRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Ovdets:Rec_LiqM__Sw._ � � �� COMPENSATION INSURANCE ADDRESS�D- � Thit�eciion naad not b�tom I�f�d ti th�wo�lc tnvolv�d b First 20 ( � y iotol No. Addilional CITY � /�� Tel.No,��jl�� tha pormit i�ior one hundrad dollurs(f100)or bss.) vIAN CMECK �1 certify that in�he performance of�he work for which this APPLI�p,NT _ �permit is issoed,I shall no1 employ ony person in ony monner — �so as to become subjec�to ihe Workers'Compensotion Lows. Lighting Fixtures First 20 ADDRESS - � - � � � Total No. Additionol CITY Tel.No. Dole Applicont Fixed Appliontes No�Over 1 HP pERMI� Y-'"�E TO APPLICANT: H, af�er moking fhis Cerfificale of qpPLiCANT� C 7�. l �ption, you should 6ecome subject ro �he Workeri Range_Heater_D.W.— . Compensalion pravizions of the Lobor Code,you must forlh- Oven _Dryer _W.M.— /�CCRESS �Q / with comply with suth provisions or Ihis permit shall be Top _FAU —W.H:— ry ��/� - deemed revoked. � � � - CIN f�/� �7'�76 Tel.No y Hood _Fon _Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. —Room Air Cond. — REG.NUMBER ! aosS.C'l0 �hereby affirm lhat I om licensed under provisions of Chopter 9 !� (commencing with Section 7000)of Division 3 0�the Buvness OISTRIR NO. PROCESSED BY . . �- and Professiom Code,ond my license is in full forca and effec�. Power Appara�us 8 lorge Appliances ` p C/ Size 8 Type HP,KW,KVA,or KVAR' �O �\O�Q V LiceneeNumber �J� LiaClois� FINAL � Up to i Ind. p ��Qrnf(.fT'-" Da�e� Over 1�0 10 Incl. DA� Z-3�� VAIIDATION U Contracloi Over 10 fo 50 IncL PINAL � W ❑ I am exempt�nder Sec. Over 50 to 100 Inc. BY n- N B.BP.C.for this reoson Over 100 Z � Date: � Services,Swbd.,MCC 8 Ponelboords � o-�oo nmP.u�de�boo v �1 7&0 A Signature - 201-1000 Amp.Under 600 V ❑ � Over 1000 Amp.or Over 600 V � . #• • • • •2 Exemption for Reg.Maint.Elet1. -- � � SINGLE FM11LY Tem Power Pole 8 A . � •-•s�'`�4. HOME OWNER-BUILDER DEQARATION P• PP�rrenances Sign with One Bronch Circuit . . s . e�j� C(„j I �by affirm thot 1 am erempf from rhe ConiraUor's Licensa �Additional Sign Bmnch Circuih � - low or�he following reoson(SeUton 7031.5,Business ond - � 0 9.2 2-8 8 Professions�ode): - . ❑ I,.as awner of the prope�ty,will do the work and�he Misc.Conduiu 8 Condudors . . strucfure is not intended or offe�ed for sale(Section Othe�(See Complele Fee SchedoleJ_ � - � 7044,Business ond Professions Code). CONSTRUCTION IENDING AGENCY I hereby effirm Ihat there is o mnsfruction lending ogency for / fhe performonte of�he work for which Ihis permit is issued PERMIT FEE - � (Sub•Total) � (Sec.3097,Civ.CJ. � PLAN CHECKING FEE � Lender's Name /� PERMIT ISSUING FEE - - - � �. Lender's Address I certify�hat I hove reod this application and smte Ihaf the 70TA1 FEE . . - �, � , above in/ormation is correct.I oqree to mmply with all Co�nry ordinances and Stoie lows�egulo�ing Eledriml wiring,and . . hereby authorize representalives of Ihis CouMy lo enter upon � the bove-mentioned property for inspe[fion p�poses. � A � SEE REVERSE FOR EXPLANATORY LANGUAGE 7 Signature of Permitlee Dote i --- ; ,. .. . , _ . :_. . _..1 . . .. ,. ;% ;'� i ; i =� i , ; ; ' , �` � ��. � i .` : � � ; ;' � ; � • ' . -.. +� ! � ! � ' i - . 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