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HomeMy WebLinkAbout1642A WORKERS'COMPENSAT(ONDECLARATION �eA663 � APPL{CATION FOR ELECTRICAL PERMIT � � � CE-806G(2�90) I hereby affirm that 1 have a certificate ot consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a cettlficete of Workers'Compensallon Insurance,or , � - � � � � a certified copy thereof(Sec.3B00,Lab.CJ. � � PolicyNo. �Company � . FORAPPUCANTTOFILLIN pDRESS tJ��L7�0 �/-{�' ��GL'] � New Residential Bidgs.&Pools EACH NO. FEE � Certified cnpy is here6y furnlshed. � 1&2-Fami�y,Sq.Ft. � - S — S LOCALITY���Qr17� /L - ; � Certified copy Is filed with the coLnty building inspection Multi•family Sq.Ft. '` CROSS ST Ip�j�/�+�-- ,� depa t -nt. . , flesidential Swimming Pools�` OWNER OR �/ . � - � �s � FIRM NAME ���N � Date Applicant��u � � Outiets:Rea._Light_Sw._\ MAIL S.�D77�6 , � ' FirSt 20 /�DORESS � CCR PICATE OF EREMPTION FROM WORKERS' ' Total No. Additional CI7Y � - ���Tai No. } '� � COMPENSATION INSURANCE - O - - � � . PLAN CHECK . (This section need not 6e compieled if the work 1nvOlv¢d ' APPUCANT V _ by the permit is for one hundred dotlars(SIOO)or las.) �'ghting Fixtures First 20 ' ADDRE55 - � . . . Additional � �� � � Total No. ' - � � � I certify.that In the performance oC the work for which this Fixed Appliances Not Over 1 HP ' ��TY TH No. . (~j permit is issued,I shali not empioy any person In any manner � _ pERM1T , ul so as to become subjeM to the Workers'Compensallon Laws. Range_Heater D.W._ . APPLICANT�� T 3 A//L ' . a . � - pven _Dryer,W.M.` Ap�R£5e�.�� � Z - � � � � 7oP _FAU _W.H._ . �w �m � — .Date Applinnt CITV�{f.�/ Tal N �j'3� Hood_Fan _Other_ � N0710E TO APPLTCANT:If,after making this Certificate of Dis0. _Room Air Cond,_ uCENSE OH � Exemption, you should become subject to the Workers' � AEG.NUMBER���3Z^C�asa � Compensetion'provisions Of the Lebor Code,you must fOrth• power Apparetul&Lafge ApplianC65� DISTRICT NO. P ESSE 8Y with compiy with such provisions or this permit shai� be Size&Type HP,KW,KVA,or KVAR . . � � deemed revaked. ' . � . UP to 1 InCL FINAL . � � Over 1 to 701nC1, DATE � . � � LICENSED CONTRACTORS DECLARATION � � �Over 10 to 50 Incl. � c2-- ��- VALIDATION . �i 1 hereby affirm that I am licensed under provisions of Chapter _ , Over 50 to 100 Inc. __ . By A� . � ' I 9 (cnmmencing with Section 7000)of Division 7 of the 8ust- Over 100 �"�- . � nas and Profeasions Code,and my license is in full force and . . , effect. � � � � Services � � � - ' � � 'License Num6er�����2' Lic.Class C�-0 OQ00 Amp.Vnder 600 V � � _ � ^ n � ZO1d000 Amp.Under 600 V . _ z 1 ��l�n � Contractor��� Date �� Over 1000 Amp.or Over 600 V � � � � � . r . . � ., •�°r' , . HOMF,OWNER-BUILDER DECLARATION - Temp.Pbwer Pole&Appunenanees -, . � . �..� � t i, �� � Sign with One Braneh Circuit' � I hereby a(£um that 1 am exempt from the ContractoPs � � - r..n x �� License Law for the following reason(Section 703I.5,Busi• �itional Sign Branth Cireuits . • - . . *-o-+���_" . .,;� ness and Plotessions Code): ' � ' ��. ' � � Mise.Conduits&Conductors . ��,2�_n� � l, as owner of the property,will do the work and the pther(See Complete Fee Schedule)— atructure is not infended or offered for sale (Section . . - ' . 7044,Business and Protessions Code). �� CONSTFtIICTION LENDING AOENCY � , t hereby affirm that there is a construtlion Iending agency � _ . for the performence of the work far which this permit is pERMiT FEE • (Sub-Total) O � ' . . issued(Sec.3097,Civ.C.). � � . � . Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel - - - . Lender's Address PERMIT ISSUING FEE � � � � � I certify that I have read this application and state that the TOTAL FEE. � - � . ' above information Is correcL I agree to compiy with all County . . .. . . ordinances and State Iaws regu�ating Electrical widng, and � . hereb authorize representatives of this County to enter upon � ' , ' � . the ve-me oned property for Inspection purposes. SEE�RF.VERSE FOR EXPLANATORY LANGUj`�GE� ' • � . . .. ._.. . . f '1 . . . . : ' l ignatu of Per ittee . � D te � � e - . _'�� 9 d1 .,i i -- _ _ _ _ +- ._ _, .. . ..... . .. _ , i: ; ; i i..,�,i. i �1 '' . ; � , , ; � � � � , : � - _ - ' ' , ; . � _ � ' � ; . � . . ; , .. i ' , � ' , ' � 7 . ,. . � - - � .. - � "_ � � � '�` • ., , , ' . . � ' . - _ .} � ; � _ �Z �n � -o 'n �. 31 C -1 . . . . i � O Z � � j� Q Z � , � � : . . � ..-I D r � ...� �: C O S :. �� { � � r � m c z � m � 'D ' ._ . . . 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