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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION � 76A683 10/81 pppLICATION FOR ELECTRICAL PERMIT � � 1 hereCy affirm that I haw a certificate of consent to self insure, CE-sosG � or a certiticate of Workers'Compensation Insurance,or a certificd COUNTY OF LOS ANGELES BUILDING AND 5AFETY copy thereof(Sec.3800.Lah.C.) - POIiCy NoC�q0�$363company{�pUS���� ,�9 FOR APPLICAN7 TO FlLL IN JOB ❑ Certified copy is hereby furnished, _,. . „ .. New Residential Bidgs&P�qL��� EACH NO. FEE A�DRESS � �� q EQp � �� "Certified copy is fi�ed with ihe county buildirg inspection �8 2-Famiy,Sq.FL `� �� — � LOCALITY ' � 25T��-V �'% � � depa�iment. � � � �- Multi•family Sq.Ft. — NEAaE57. . m DateTq 3� $' � Residential Swimming Pools CROSS SL ;�/��j(-} I�APPlicant . , . ._. .. .. OWPIEROR �n ' FIRM NAME R �- CERTIF�CATE OP EXEMPTION FFOM WORKERS'�- - Outlets:Rec—L'ght_Sw.�— . � � �`�� ^ � 4 � � � COMPENSATION INSURANCE� _ . .�. ' .- . �� . ADDRE55 I SI�� RIL�A y �' N (This section need not be completed ff the work involved by the Frst 20 p permit is for one hundred dollars(5100)ot leee,) , Total No: Additional � ��TY OS� �5��� 2(�2GTe�.Nop ^'00� I certify,that In the performanee of.lhe work tor which this�permit � _ � , _ ' - P�rv cHeCK �- is issued,I shall not employ arry pE�Son in erry manner so as to - ����� _ �betome subject to the Workers'Compensation,Laws. . L'ghtirg Fixtures Frst 20�- - - �ADDRESS - --.- � . � . . � Additional � �� : �-� � � . Total No. CITY � � � - -� Tel.No. Date� APP�icant � � � Fxed A IianCEs Not Over 1 HP NOTICE�TO,APPLICANi: If,.aRcr making ,this Certificate ot pP PERMI7��..�' Exemption,you should become subject to ihe Workers'Compensatbn . Range_Heater_D.W. A����'�T C ��C �- t , .pmvisions of[he Lzbor Code.wu must forthw th comoly with such Oven_ Dryer_.W M._ AODRESS QO.� ,1 f � .provis ons or this perm't shail be deemed revoked. �, � .,, To FAU W H._ '4�„ � � .� UCENSED CONTRACTORS DECLARATION � � � -� --�� � � - '� CITY '� ��b , \l�� `Tel.No.S ,6 y(� � �. - - .. . � ... Hood_Fan _Other_ � � I hereby atlnm that 1 am IicGnsed under provisions of-Chapter 9 _ uGENSE oR S��7 � � � Disp. _Room Air Cord. -_ REG.NUMBER� OO�V U ��'s��-�0 i (commentmg with Sedion 7000�of Division 3 of the Business and � - � Professions Code,and my Iicense is in full force and effect.� otSTA�CT NO. PROCESSED BV , Povrer Apparatus&Large,Appliances _ , _ .. _ ._ . .. ._.._ .. _ ' � Size&Type HP,KW,KVA,or KVAR � � t License Number y�D O�3 �.-�6 . ', � �C �G � h Lic.C�ass .... .._ ... _.Up io-1 InCI:....._. _ .. ... ... ._ _ FlNAL . �p� . . _ _._ . _ .. _ � I �EG'^f C/{/ .- .,. � Over 1 to 70 Incl. DATE /'1�Z.�VY �. Contractor f l ' � Date��� . _.. .. . .. �L O(1 __ VALIDATION 0 , Over 10 to 50 Incl. � � '� FINAL F" ❑ 1 am exempt under Sec. - � � - _,_ .__ Over 50 to 100 Ix. � BY W I� BSP.C.fo�ihis reawn Over 100 � � �- �- . ... . ... .. . . � i � � -- -Services;Swbd.,MCC 8 Panelboards � - -- �- ' �-- � � -� -� Z i - - � � �Date: 0-200 Amp.Under 600 V �1 1 fl 2 A ^ � Signature -- � 201-�1000 Amp.Under 600 V - -- - �- - -�� -� -� ��� � - � i . _. . _ . . _ .._._ .._ . _.. __ _ . Over 1000 Amp.or Over 600 V �• • • • •'Z. ' � Exemption to�Reg.Maint Eiect - . . . . .. . ._ .. . _ . _._. . . i _ I � 12646 � - - -�- ��-- SINGLE fAMILY- � Temp.Power Pole 8 Appurtenances _ .. f' I hereby affirm that I am exempt trom the Contrector's License Law 9 _� � ' ' � ��4�� HOME OWNER-6UILDER DECLARATION Si n with One Branch Circuit for the lollowing reasbn(Section 7031.5,Business and Professions Additional Sign Brench Circuits . � ❑e,�l,as owner ot the property,wili do t(e work and the structure Other See Com I � � -�- --, . -. .. _ . ��2 6-s� Misa Conduits&CorMuctors � - is not intentlstl or ofleied tor sate Section 7044,Business ( Pete Fes Schedule)_ ► and Professions Codel. . - .. __. . . . .... ..... .. . . . . . . __ .. CONSTRUCTION LENDING AGENCY - � � -� � � - - . . . . . 1 hereby affirm that there is a construction IeMin9 agency for the - . . � performance o1 the work tor which�his permit is issued�Sec.3097, __. pERMIT FEE - � � - - �-� � {Sub-Total) � �-�"'- - .. .. Civ.CJ. ._.. . .._ . ..,. . . .PLANCHECKINGFEE. . -.. - .. ...._'.. . . . _ . . . ._. ._. _ . . . . Lender's Name . __ PERMIT ISSUING FEE_ __ __, ..�D �O . ...... . . ._ . .._ _.._ .. . .. . ._ . . .._. . Lender's Address � ^!� �� I certify that I have read this application and state that the a6ove _ TOTAL FEE o�b . ...._ ..._.._.. ... -_'_ __. __. _ . . .. ._. .... __-- intormation is correct.I agree to compiy wiih all County ordinances �-� � and State lavrs regulating Electrical wirirg,arid herehy authorize � � representatives of this County lo enter upon the abare-mentioned � � � � � ' � � � -- �- � - - � � -- � ' - � - - - - property for inspection purposes. � � - � �r n ��Q . g� ac . . .' ... SEE REVERSE FOR E%PLANATORY LANGUAGE _ . . . _. . . . ._ .. ... .. . . . . . .o! 0 6 Signature of Permittee �e ' . � ����c'.�.-^.f_•.`_�� . . ,;.._ . �+� i- -�; -i- r--i- i���"i�----+��, � _ j (, i". ! . 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