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HomeMy WebLinkAbout1448A (8) 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 r�,�-� [� ^ ^, �) ` Certified copy is he�e6y fumished. New Residenfial Bldqs.8 POals EACH NO. FEE aDDRE55 �/�1 � 1,=�I L.� -• � V-'�J:� �� Certified copy is filed with the county boilding inspec- 1 8 2-Family,Sq.Ft. S = S ����ITY� � ; �,� 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���.,- ���� Thls sxYion naad no}bo com IaNd 1(16�wo�k involved b Flrsf 20 ( P Y Tota�No. Additional Cltt 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���M Exempiion, you shoold become eubjeU ro th¢ Workers' Ronge_Heafer_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 the performance of ihe work(or which Ihis permit is iszued 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 regololing Eiedriml wiring,ond � . . r hereby authorize representalives of Ihis County to enrer opon � � the above-mentioned propeny for inspection purposes. 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