HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATIONDECLARATION • 78A883 ,o�a� AppLICATION FOR ELECTRICAL PERMIT {� � I here6y atfirm fhat I have a certificate o1 mnsent to selF inswe, C6806G or a ce�tificate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY LJ copy ihereol ISec.3800.Lab.C.) Policy NoC�OL$�c6moariv1��Usl'Gl�f3l. ,f�� FOR APPLIC�N7 TO FlLl IN . . . . .- .. . DDRESS Q3 ' V`�. � U`� .� ❑,,Certi(ied copy is heroby furnished. , , . ., New Residential Bldgs.8�0l�/J/J EACH- ND. FEE - 'j` .141 . . �, . � 1 8 2-FamilY.Sq.Ft.�1LL_ � — S LOCALIT 2 S� �V I: �'Cerfified copy is filed with the�county buikling inspection ���� departm=nt. .� Multi-lamily Sq.FL ROSs Sr. � • •�'1'1� Re5ldential$wimmirg PO015 OWNER O!2(2 n �ate 30 $ APPlicant ..� .1 1'' ' . , , . _ . _ _.. _.. FlRM NAME`F� rT ���' . CERTIFICATE OF EXEMPTION FROM WORKERS' � -- . . MAiL 4r ` - •�- . COMPENSATION INSURANCE � , Ouflets:Rec_Light_Sw.— . _� - po�nES53�S� lu �• �v �� (This seetbn need not be rompleted if the wwk irnolved by tbe Frsf 20�-- �permit la for one hundraA dollars($100)or less.) . Total No. Addi[ional���' CIT d�A . � � Tel.No. sO-�00 I certify�[haCin ihe rformance of the vrork for which this ermit . _ . . � _ � �N CHeCK P� P � 'i APPIJCAM �is issued,�l shall rrot employ any person in arry mannerso as to - - become subject to the Workers'Canpensation Laws. .,, . L'ghtirg Fxtures First 20� � --� - ��-- -�-- � -- ADDRESS�� -�- � � �- �- '"�� - - � -�" "- �� ' -� - Total No. Additional _. � � CITY � - -- --�� �' Tel.No. Date - Applicant �- ��� � � � � Fxed Appiiances No[Over 1 HP NOTICE TO-,APPLICANT: If,�atter�.making this.�C2rtificate of �ERMii ' C Exemption,you shwld become subiect to the Workers'Compensation .- _Rarge_ Heater O.W. _ AP���`�'�T F- �1�C '�\ - � �provisions of the Labor Code,you must forthwi[h comply with such Oven_ Dryer_ W.M._ PDDRESS � �dX ���� ( provisions or this peimit shali bo deemed revoked .� . . . .__ __..Top-—FAU _ W.H._. � 4 LICENSED CONTFWCTORS DECLARATION Hood— Fan _ Other_ CITY� � � 1 d Tel.No.JCQ��(�Y6� I herehy aifirm that 1 am licensed under provisions of Chapter 8 -- Disp.--Room Air Cond.- uceNSE or� (J q p .... . . ._ .._ _._.. REO.NUMBER 7 1 d� 03._"' Cless.C� D � (commencirg with Section 7000)ol Divisian 3 of the Business and — PIOfe55ions Code,Etld my Ncense i5 in fNl fOrCe a�d eiTect. DISTRICT NO. PFiOCE55ED BY _ .. Power Apparatus&Large Appliances . . -. - . .. . .. � �l ,(� . � � � Size&Type HP,KW,KVA,or KVAR L C� 1 '\a.\Q.,�E� Q License Number '-19 0 0�3 Lic.Class e-�� � �-� Up to 1 Incl. - -�- � - � � � �� � FlNAL � � � � � - ' - `--' Over 1 to 10 Incl. OATE Z:� _ypLIDATiON � �Contractoi E��ft�l C��=-oate zTP - over to m so�nci. ... . . 2� ' ..-� U . FlNAL _Q,,I am exempt under_Sec. -� •- � � Over 50 to-700 Inc. . gy --� .. W 6.8P.C.for this reason Over 100 L1. I � Services.Swbd.,nncc a Pa�emoaras . .- - . . � .. -. . . .---- � � �1 1 (z 7 A N � ..._ .. .. ._. .Date:.. . . .. __. Z 0-200 Amp.Under 600 V Signature � 201=f000 Amp.Under 600V - -" � ����� � -�-` �-"- #� � � � �-2- � _ a.zr i000 nmv.or a,�r soo v I • �9 4 2 6 Exemption ior Reg.Maint Elect. � � �� � - �� � � - � � � _. . . . ........ . . � x �SINGLE FAA?!LY� � ��� Temp.Power Poie&Appurtenances • • •9!z?G c� � - _ - _ __ . ._ ._ _ HOME Ol'VNER-BUIL�ER OECLARATION Sign wRh�Branth Circuit - I hereby affirm that I am exempt from the Contrador's License Law qdditional Siyn Branch Ciraits .- 0 B 2 6-8 s tor the fotiowing reason 1Section 7031.5,Business and Professions � �� - '� � ��- ��� �-�- -� - --� -�- -- �� � � Code): � � - Misd Corduits 8 Conducfors . .. . -- ..- _... � . . --- ` . . '� . . I,as owner oF the property,wiil do ihe xrork aM the 5lructure is not intended or offeretl for sale(Section 7044,6usiness Other(See Complete Fee SchedWe)_ � .. and Professions Codel. ..- . . - � .. . . . . _ -- .. .. . ..-._. . CONSTRUCTION LENDING AGENCY - � � � -� --- � � -- � -� -�-�--- � 1 hereby affirm that there is a construciion IeMirg agency for the perFormance ot Ihe work for which Ihis permit is issued(Sec.3097,-- pERMtT FEE �-�� ����� ''-� � - '`- -'(Sub-Total) - g S- 76 � ���-� -- � - � -� � - -� � � Civ.C.I� . .. � .�. � - PLAN CHECKING FEE. ... . . . . . .. .___.. ._ . . . _ _ . . . _ . ' . Lendcr's Name • � . PERMIT ISSUING FEE.. __._.. . ._ . ._ . . _ D �j .__. . . .. . . . .: _ _. .. Lentler's Add2ss • -�! ,�` I certify that I have read this application and state tFkii the above. - TOTAL FEE __,. ____.., . _ , b t0 . _. . ..... _ . intormation is corrett.I agree to comply with ail CouMy ordinances . and State laws regulating Eledrical wiring,antl hereby authorize . , .,. _ .. _ . . _ . _ . . __.._ _. . . .. . . .. _ .___ . rep2sentatives of this County to eMer upon the abare-mentioned - �-- -�� ��� �-� pioperty for Inspection purposea . . - . 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