HomeMy WebLinkAbout1574A (9) WORKERS'CQMPENSATIONDECLARAT[ON ' 78A663 APPLICATION F4R EL�CTRICAL PERMIT ///���
�� � - � � CE�906G 12-801 �
[ herebv afEirm thet I he�e a certificate of consent to sele COUNTY OF LOS ANGELES BUILDING ND S FETY
insure,or a certificate of Workers'Compensation Insurance,or �77c� ��6� ��
a certified cnpy ther of(Sqec.3800,Lab.C. ��+�6�
+ Policy No. 7Q�/Co npany J FOR APPIICANT YO FILL IN �pg �/D�� � �Cf
� New Residentiai Bldgs.&Poo�s
EACH NO. FEE ADbRE55 g�'/�����
� � C �fled copy is hereby Pornished. 1&2-Family,5q.FL a — S LOCALITY ,,� �
� � Multi-family Sq.Ft. N A T
I Certified copy is filed with he county 6uild' nsp ion CROSS ST c�
� department. Residential Swimming Pools ���WMER OR �i1,
I Date��pplica � �1 I \ F�RMNAME /1�
Outlets:Rec��light�BwZo a7�j S 7 qDORESS � / �' es /i/
� CERTIFICATE OF EXEMPT FROM WORK£RS' Total No. � Additional
'i COMPENSAT[ON INSl1RANCE PLqN CHECK u Tel No. �
(This sectlon need not be rnmpleted if the wock imolved �;� '� APPUCANT V
' b Lighting Fixtures First 20
y the petmit is for one hundred dollazs (5100)or less.) ADORESS
Total No.� �ditional O
1 cectify that in the performance ot the work tor which this Fixed Applianees Not Over 1 HP CITY Tel No.
permit is issued.I shall not emplay any per�on in any manner PERMIT V
so as to become subject ro the Workers'Compensation f.aws. Ran9e�Heater_D.W. APPLICANT ��`i � �� d
Oven _Dryer_W,M,_ ADORESS 1 � � � r� �� Z
' Date Applicant Top _FAU _W.H._ L —
' Hood_Pan _Other� CITY Tel No . �
NOTICE TO APPLICANT:IF,after making thia Certificate of Disp. _Room Air Cond.__ L+CENSE OR- -
Exemption, you should 6ecome subject to the Workers' REG.NUMBER 7�C1ass C�
Compensation provisions of the La6or Code,you must forth- Power Apparatus&Large P.ppliances DIS7FifCT NO. PFOCESSED BV
' with comply with such Drovisions or this permit shall be Size&Type HP,KW,KVA,or KVA �
deemed revoked. �
� � UP to 1 Incl. I �
Over 1 to 101nc1. FINAL
� G[CENSED CONTRACTORS DECLARATION DATE � VALIDATION
Over tOto 50 Incl.
p i hereby affirm tfint[am licensed under provisions oP Chapter Over 50 to 900 Inc. fiNAL
BY
� 9 (commencing with Section 7000)of Division 3 of;he Busi- Over 700
ness and Professiona Code,end my license is in full(orce and . ..
effect. Services
G� 0-200 Amp.Under 600 V
� License lVumber � � � Lia Ciass �`-7 ��.���p Under 600 V
i Contractof�S �F . Date�� ��-4 / � Ovar 1000 Amp.or Over 600 V �
� :�i 5 7.4 P,
HOME OwNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �
[ htteby aff'vm that 1 am exempt from the Contractor's Sign with flne 8reneh Circuit �• • • • •2 .
License Law Eor the foliowing reasun(Section 7031.5, Busi- Additianal Si9n Branch Circuits ' � • • � �',7 5
ness and Rofessions Code):
Misc.Conduits&Conductors � � � � g�5`
� I, as owner of the property,will do the work and the Dther(See Complete Fee Sehedulel�
structure is not intended or ofEered tor sete (Sectian
'I044,eusiness and Professions Code). I O,2 C��7
CONSTltUCT[ON LENDING A(3ENCY
[ hereby nffirm fhat there is a construction lending xgency
for the performance of the work for which this permit is pERMIT FEE (Sub-TOtall
� issued(Sec.3097,Civ.C.). 7 Jr
Lender•s Name PLAN CHECKING FEE (One-Fourth Permit Feel
Lender•s Address PERMIT ISSUING FEE G �
1 certity that 1 have ad is ication and state that the TOTAL FEE l 9 5
abov � armation i orr t.l e to comply with ail Coanty
o n ces and at aws ulating Electrical wiring, and
er euthor' r rose 'es of this County to enter upon
th a ve-m d pr rty for inapection purposes. SEE�REVERSE FOR EXPLA�NpTORY LANGllAGE
/ /a d"/�/
Signature of Permittee Dete �
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