HomeMy WebLinkAbout1448A WORKERS'COMPENSATION DECLARATION . 76A66� 10/81 ppp��CATION FOR ELECTRICAL PERMIT � �
I hereby affirm ihat I have a ceriificaie o(consent�o self �. CE-eoSG
inwre,or a cenifimre of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILOING AND SAFETY
or a certified copy Ihereof(Sec.3800,tab.C.) � ��,
P�olicy No. Company . FOR A►►LICANTTO flll tN JOB -Y ,�-� [� ^ ^, `
Certified copy is he�e6y fumished. New Residenfial Bldqs.8 Poals EACH NO. FEE a�DRE55 ��� � ,,^I`.� -• � l�'�J<�
�� Certified copy is filed with the county boilding inspec- 1 8 2-Family,Sq.Ft. S _ S �����T� � ' �'�
lion deportmenf. - Multi-fomily Sq.FI, � CROSSSSi. �U�1� �i N L'��
Da}e Applicont Residenfial Swimming Pools OWNER OR y/� r� ��-
FIRM NAN�E ��' L� �/
�CERT�FICATE Of EXEMPTION FROM WORKERS' Outlets:Rec_tight_Sw._ 'ViP'��
COMPENSATION INSURANCE � ADORESS���.,- ����
TI�Is sxflon naad nof be com laNd lt 1h�wo�k involv�d b First 20
( P Y Tota�No. Additional CITY Tel.No.
fhe permif h for ona hundr�d dollar�(5100)or I�ss.) . alnN CHKK
1 certify ihat in Ihe perfarmance o(Ihe work for which this APPIICANT �
permit is issued,I shall nof employ any person in any manner —
so as�o betome subject to ihe Workeri Compensation laws. Lighting Fi:l�res First 20 ADDRES$
� � � Tatol No. Additionol CITY Tel.No.
Do}e eppliconl Fixed Applionces Not Over 1 HP PERMiT
NOTICE TO APPLICANT: If, vNer making this Certificaie of AP���AM
Exempiion, you shoold become eubjeU ro th¢ Workers' Ronge_Neafer_D.W._ .
Comoensation provisions of the labnr Code,yov mpsl forth- Oven _Dryer _W.M.— � ADDRE55
with comply wi�h such provisions or lhis permit shall be Top _FAU —W.H:— �
deemed revoked. Hood —Fen _Othar_ - CITY al.No.
LICENSED CONTRACTORS DECLARATION pCENSE OR .
1 hereby affirm rho�I om licensed under provisions of Chopter 9 � Disp.�_Room Atr Cond. — ReG.NUMBER u�
(commenting with SeUion 7000)of Division 3 0(fhe Business DISTRICT NO. PROCESSED Y p�,�
ond Professions Cvde,and my licenze is In full force and eNec�. Power Apporatus 8 torge Applionces �.
�.�^iJ—r . Size 8 Type HP,KW,KVA,or KVAR � U
Ucense Nomber�`� -L ,� lic.Closs � � PINAI �
Up to 1 Incl. pA� r�/!3/ / � -
� �Q � t�: ;��S^ Over I Io 101nd. l l�� VALIDATION U
Contracror%}, �'v G ,` Date��` � Over 10 fo 50 Ind.
OFINAL W
I nm exempf under Sec. Over 50 to 100 Inc. BY �.'
Over 100 N
B.BP.C.for this reason Z
Dafe: ' Services,Sw6d.,MCC 8 Panelboards - �r
0-20QAmp.Under 600 V �' J
Signaiure �201-7000 Amp.Under 600 V
_'1 [t'[!8 A
aOver 1000 Amp.or Over bpp V •
E�empiion�for R .MoinL Elec�. � �� � � .�2
- SINGLE FAMILY Temp.Power Pole 8 Appurtenances - � � - � �
E OWNER-BUILDER DECLARATION Sign wiih One Branch Circoit � ° •C:�Jr�
I he�eby irm�hm 1 am e.empt(rom the Contracror's license Additional Si n Bronch CirwNs �
Law f ihe following reason(Sedion 7031.5,Business and 9 •.� •G�')�F
Prof sions Code): � .
Mtsa Conduiis 8 Gonduc�ors � �,�� �—�5
� I,az owner of the property,will do�he wv�k and the
strucfure is not inlended or offered for sole($ection Other(See Complafe Fee Sthedule)_ ,
7044,Business Und Professions Code). �
CONSTRUCTION LENDING AGENCY -
I hereby offirm�hat�here is a constructian lending agenty for
tha performance of ihe wark(or which Ihis permit is issued pERMIT FEE (Sob-Totol) -�
� (Sec.3097,Civ.C.J. �
PLAN CHECKING PEE
- Lender's Name � /
PERMIT ISSUING FEE Q . �I .
lender's Address
I certify that I have read this opplication and stale Ihal the TOTAL FEE .. . � 0'S .
obove information is m�rect.I agree�o tomply with alt Coonry �
ordinances and Stote lows regvloling Eiedrical wiring,ond � . . r
hereby authorize representalives of Ihis County to enrer opon � �
the above-mentioned propeny for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �
�-���i �1 i,•
C u✓ �.,L '�!/�'��� � �
.�•Signoture of Permitlee Date �
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