HomeMy WebLinkAbout0842A (4) � WORNERS'COMPENSATION DECLARATION 76A663 IOiel �O�J � fa�•"��'�v , �
I hereb affirm that I have a certificaie of consent to 5e�f �E.� APPLICATION FOR ELECTRICAL PERMIT i
insure,or a certificoie of Wo�kers'Compensation Insurance� ' C�UNTY OF LOS ANGELES BUILDING S FETY'� ��/�
or a certifiwe�d,c�opy ihe�eo((Set.3800,Lab.C.) r� O' / �y�GLt/
P❑olicy No."`'��#!D�Company s T,�r� /`Y/IY 1? FOR A/PLIGHT TO FllL IN �pp�pRESS �N• � �,
Certifiad topy is hereby(urnished. � New Residentiol Bldgs.8 Pools EACH NO. FEE
� - 1 8 2-Famil Ft. f — f LOCALITY � 3�q ,
Cer�ified copy is filed with the county buiiding fnspec- Y�SQ•
lion department . Molfi-fomily Sq.Ft. — NFAREST . �
'���_�3-� . Residenfiol Swimming Pools OwhSiER OR �7
Dote Applicant . . . . Y/�C C N�L/PU lt
. . fIR�A NAME
CERTIFIGATE OF EXEMPTION FRO ORKERS' � � nMa �
Outlels:Rec_light_$w._ pppRE55
- COMPENSATION INSURANCE' � �'S aQ } �
hb sMlon ne�d nof b�eom IN�d if Ihs work Inwhed b First 20
R P Y Totol No.� Additianal 6 J CIN Tel.No.
iha pormN it for ons hundnd dullun(S1W)or Is�r.) - Vln CrIKK
I c�rtify that in the performance of tbe work for which this � ` AVVLiCANT :�+-�S . � - C^ I
- permil is issued,I sholl not employ ony penon in ony monner —
so as to become subject to Ihe Workers'Compensation Lows. Lighting Fixtvres Firs�20 S ADDRESS� � /n/!� .
`�S Additionol
� � � , . Totol No.� CITY Tel.No. '
. Date � /PPlitont Fixed Appliances Noi Over 1 HP PERMIT ��� �J��3 � �'
NOTICE TO APPLICANT; If, after moking ihis Certifitote.of AVMICANT / �� ?
� ExemMion, you shouid become subjed �o�he Workers' . Range_Heater_D.W._ ,
Compensation prorisions of the Labor Code,you-must forth• Oven _Dryer _W.M._ ADDRE55� �
with comply with soch provisions w this parmit sholl be Top._—.FAU —W.H.— .
deemed revoked. � ��� �- � � � � Hood _Fan _Other_ . CIN - � - Tel.No. -� .
LICENSED CONTRACTORS DECLARAT�ON � . uCENSE OR �
I hereby oHirm that I am licensed vnder provislons of Chopter 9 � Disp: —Room Air Cond. — REG.NUMBER (� Closs, �� �
(tommencing wi�h Section 7000)of Division 3 of the Business DISTRICT NO. D BY
� Power Apporotus 8 Large Appliances .. Y
and Professions Code,ond�my license is in iull force and effetL - � - - '-�-' ��-� '� d
� 7� Size 1& ype HP,KW,KVA,or KVAR� u �f � Q�vr� � Q �
License Num6er 375 a 7a lia Class � �u �7 Up to 1 Incl. r•Q� r ' � � fINAL - . . . . .. - . . V �
ContraUnl�1.�� � +�+ � pme «'�3-OJ i Over 1 to 101nd. ��00 �ATE VALIDATION_ Q �
O � Over 10 to 50�ncl. fINAL � � V .
�I am ezempt under Sec. Over 50 io 100 Inc. BY �++
� ' _fiL_ Over 100 Z.
6.8P.C.for�his reawn - . ,
- Ddte: Services,Swbd.,MCC 8 Panelboards - � � - � � __
0-200 Amp.Under 600 V '-�'�a���� �
, Signofure lUl-1000 .Under 600 V �� � '; o e a �
❑ � Ove�.or Over 600 V � r�. � 3� �
Ezemption for Reg.MoinL Elecf. ,�.:x,"? S^
SINGIE FAMILY - -. Temp.Power Pole 8 Appwtenonces _ . ' °"��• �'��''�
- HOME OWNER-BUIIDER DECLARATION � Sign wilh One 8ranch Cirtuit � (i 1 L ii-i:�+ �
1 hereby affirm that I am exempt from the Conlractor's Litense Addifionol Sign Branch Circuils - �� - - �
taw,for the following reoson(Section 70.31.5,Business and . � � �"-� .
Professions Code): �
❑ I,as owner o(the ro e wJl do the work ond ihe Mist.�Conduits 8 Conduttors � � - �-- -- � � ' � �
P P �� Other See Com lete Fee Schedule ,
structure i5 not intended or offered{or m!e(Secfion � P )— . '
• 70M,Business and Professions Code). � . ,
� CONSTRUCTION LENDING AGENCY � �� � - -- � �
I here6y aHirm that there is a conStruttion lending agency for �
the performance of the work for which this permit•is issued PERMIT PEE� - . {Sub•Totol) �3 G � �� � . � -� �
(Sec.3097.Civ.C.). . . • � � .
� �� PIAN CHECKING FEE - ..- . .-.... Sb SJ �� . _.. . . . . � ,� . . '.
Lander.'s Nome . � � — —� -- �
. � - - PERMIT ISSUING FEE ' . , . �. �. iv� `.'�� . . .
Lender's Address y�7 � ;V iV a �(,� .
1 certiFy ihat I hove read 1 applicaiion and stole Ihal 1he TOTAL FEE - . � .�O/ S - - � �O -O . N ,
� above.information is corr t.I gree to comply with oll County , - p �Jo m o� o �,
ordinances and S�ote I s r ul i g Electrical wiring,and ._. .. . . _ � �n c.q -+ n � �
h y avthorize repr ent vez this Counly to ente�upon . - � �,+ �, p .p ij � �
e 6ove-men one p� rty inspection purposes. SEE REVERSE FOR EXPIANATORY IANGUAGE ��{
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