HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATIONDECLARATION 76A669 �o�e� APPLICATION FOR ELECTRICAL PERMIT j� -'
I hereby affirm thof I have a cartificote of conseM to self �E-�
Insure,or a cenificate of Workers'Compensmion Inwronce, �OUNTY OF LOS ANGELES BUILDING AND SAFETY ' ��
or a certified copy thereof(Sec.3800,Lob.C.)
� POol�icy No. -�9�� ���'ompony SNA FOR A►►IICANT TO flll IN � "� �� _� �
�ertified copy is hereby fvrnished. New Residential Bldgs.8 Poots
EACH NO. �E A�DRESS �jt�' Z j�.
� Cehtified copy is filed with�he co�nfy building(nspec- . 1 8 2•Fomily,$q.FI. 311'id' s — E LOCAUTY TR� 32S - .
tion department. - � Mulli-family Sq.FI. � — NFAREST � _
� � Residential Swimmin Pools cvOSs 5T. .
Dale-_{��A3 APPIicaM ��'� Mn('�a��le.-};..iC 9 ' OWNEROR . � �
� � - � . . FIRM NAN�.J. Srock �-& Sons
� CERTIFICATE OF EREMPTION FROM WORKERS' Outletst Rec_Light_$w._ � N'P'�� 1698 Greenbriar Ln. #224
COMPENSATION INSURANCE � � � First 20� �� AooREu
(ThI�satfion n�ad not bs eompl�Nd tf fh�'werk inrolv�d by To�ol No.� 4 Addirional - CIN Brea � Tal.No529-8170
_ iba parmit 1�for one hundrod dollon(SI00)or less.] � � alnN CHKK
I certify that in Ihe performance of the work for which this - . APPLICANi
permif is issued,I shall not employ ony person in any manner - .
- so as to become subjecf�o the Workers'Compensation taws. ��ghting Fi�fures First 20 ADDRESS � - -
� - � ' Tatol No. 1 Additianol
CITY Tel.No.
Date epplimnt � � Fixed Appliances Not Over 1 HP � PERrnii
NOTICE TO APPUCANT: If,'aRer�moking this Certificote of n n .
�_)mption, yoo shoold betome svbjett to the Workers' Range_Heoter_D.W._ /+PPtiCANT
npensation provitions ot Ihe Lobor Code,yoo must forth. Oven _Dryer W.M.—�� � ADDRESS z390�S R�3e
with mmply with svth p�ovisions or this pe�mit shall be Top —FAU� L W.H.— •
deemed revoked. . .. � � - CITY ��� �POApIIa ' � Tel.No$2'7-0936�
UCENSED CONTRACTORS DECIARATION Hood _Fan �_Other_
� Disp. —Room Air Cond. — LiCENSE OR Clau. �
I here6y affirm thot I am licensad under provls�oes o(Chop�er 9 � 3 REG.NUMBER �153378 C-10
(commencing with Section 7000)of Division 3 of the Business DISTRICi NO. � PROCESSED BY
and Prafessions Code,and my license is In full force ond eHect Power Apparatus&large Appliances .. .. . . Y
d
- Size 8 Type HP,KW,KVA,or KVAR� � �
License Num6er 1S337H � Lia Class 'C�lO Up l0 1 Intl. .. . . FINAI . . . . � ... U
CoMretlor Electrical Date SIHIH3 -- Over 1 to 10 Ind. DATE ,��. _,�� P- ? VALIDATION Q
C�
❑ . Over 10 fo 50 Incl. � . ►- -
FINAL
I om exempt under Set. Over 50 to 100 Inc. BY _ �
B.BP.C.for this reason Over 100 - y
. . . � "- Services,Swbd.;�MCC 8 Panel6oards � - ►�� �-- � � ? �
Date:� 0-200 Amp.Under 500 V �
SignaWre � 201-1000 Amp.Under 600 V � - - � - -
❑ Over 1000 Amp.or Over 600 V
Ezemp�ion for Reg.Mainf.Elect.
$INGLE FAMILY Temp.Power Pole 8 App�rtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � '=n 9����
'' �eby oHirm ihaf I om eaempt from�he Contractor's license � ( �
}for the foliowing reason(Section 7031.5,BuSiness dnd Additional Sign Branch Circuits � . . _._ .. _ +�.,.� . � .2
-P�ofessions Code): � . � '
� � Misc.Conduils 8 Conductors -� . �" �'- -�-� - � • � J 9.� �
I,as owner of the property,will do the work ond the
structure is not intended or offered for sale(SeUion Other(See Comp�ete Fee Schedule)_ , �-'I j Q,� 1 u `
7044,Business ond Professions Code). , � . �
CONSTRUCTION LENDING AGENCY -- - � - - �� � -G v.� 2-3 3-
I here6y affirm Iha1 there is a conslruclion lending agency for . .
ihe performance of ihe wo�k for which this permit is issved pERMIT FEE � - - - � � (Sub-7otal�� - -. . . . . . .
(Sec.3097,Civ.C.). � . � -
� � - � PLAN CHECKING FEE _ .. . � .
lendar's Name - � � �
PERMIT ISSUING fEE .. .. . ZO S �
Lender's Address ' - �� � - � �-� . � -
I terti(y�hal I have raad this opplita�ion ond sta�e thot the TOTAL FEE � - .j3<j�l _ _ ,
above informa�ion is correU.I agree�o comply wiih ail County � �� � �
ordinances and Stoie laws regulo�ing Electriml wiring,ond _ �
hereb a �oNze representarives of this County to enter upon � �� � �� - � � � - - - � ���� � - �
the e emione ceperty for inspec�ion purposes. SEE REVERSE FOR EXPLANA70RY IANGUAGE
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