HomeMy WebLinkAbout0768A WORKERS'COMPENSATIONDECLARATION 76A667 ,a,a, APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm�hot I hnvc a ceri�ficote of consr.nt ro seli CE-806G
insure,or a ce�tif�co+e of Wo�keri Comper+sor�on Ins�ronce, . COUNTY OF LOS ANGELES BUILDING AND SAFETV
or a ceriifiwd copy thereof(Sec.J800,Lnb.C.)
P❑oi�icy No. Campony FOR A►PLI[aM TO Flll IN �Oa /p-/
Ce��ifird copy is hereby furnishr.d. New Residentiol 61dgs.8 Poo�s EACH NO. FEE A�RE� f3" `�I�"�1�/�OV6Q�
� Cr.rtified conY�s flled with the caunty building inspec- 1 8 2�Fomily,Sq.Ft. E — S ��CAIITY Q�i)/L�dA/�7 �R �j/]�
tian departmeni. Multi-fomily Sq.F�. — NEARE57
caosssT. �10:/NT�fi�cl l�4U/6t ct7
Doie q �;�a�� Res�denliol$w�mming 7oo�s OwNER OR
PP F:RM NAME N/6N/PA�y , yil�-1BAo
CERTIFICATE OF EXEMPTION FROM WORKERS' Ouilels:Rec�Lighl�5w.� MAI� �
COMPENSATION INSURANCE ADDRf55 S/ �� G'� I1C O�
Thl�s�dion nsad no1 bs eom I�f�d if fh�work involred b �/ Firsi 20 .
( P Y Total No._.L.L Ad<iitional CITY A/^, �,� Tel.No.���
tha parmil i�►or on�hundred dollan(SI00)or lass.)
I cer�if that in fhe er(ormonce.oF rhe work for which�his PIAN CHECK
Y P APPIICANT
permit is issued,I sholl nof employ any person in ony monner
so os�o become subjecl in Ihe Workers'Compr.nsalion Laws. Li9h�inq Fix�u�es Firsl 20 ADDRES$
��7 p (�/�70�GEGTl�/C, T°'al No. Addiiionol
Dote Applicant CITY Tel.No.
NOTICE TO A PLICANT: li, afler ma4in �his Ce�tilicaie of FiRed Appliances Nor Over 1 HP PFRMiT tr
9 ROn P HBa1BI_�.W._ APPIICANT /�� G`��R�G
ExempKon, you should become subjec� to Ihe Worke.rs' 9�-
Compenso!ion provisions nf 1he Lobor Code,you musl forlh- Oven _.Dryer _W.M._ ADDRF55 ¢�! u,+�g,rt�,�W�y�p �p
witli comply w'Ih sucii provrs�ons o� �nis permil Shoii oe 7op _FAU —W.H._
deemed revoked. Hood _Fon _O�her_ CITY L� �((E�A/7�C� Tel.No.� u3
IICENSED CONTRACTOR$DECLARATION IiCENSE OR Y
I hereby aNirm�hoi I am licensed unde.r provisio�s of Chap�e.9 Disp. _Room Air Cond. — RFC,.NUMBER �p' Closs. C/Q
(commencing with Seciian 7000)of Division 3 of ihe Bus�ness DISTRICT NO. PROCESSED BY
and Pro!rssiors Cedr.,and my license is in full io�ce and effec�. PO1i"er Apporatus 8 Large Applionces / �
��I,, Size 8 Type HP,KW,KVA,or ICVAR V O
License Number�G�'' Lic.Closs G/b Up lo I Incl.� F�N'4� V
��U ��' �� Over 1 b 10 Ind. DAiE Z��,��v '�� VALIDATION Q
Conrrnttor ��9aie 7� Ovr,r 10�0 50 Intl. ^
FINA ~
❑ I am e.emp�under Sec. Over 50�o 100 Inc. BY'`� uVi
8.8P.C.1or ihis reason Over 100 -!_ N •
Services,Swbd.,MCC&Panelboards Z �
Dote: 0-200 AmP.llnder 600 V , '�
SignnWre 201-1000 Amp.Under 600 V
OOver 100D Amp.or Ova�600 V
E=empno�fo�Reg.Moint.EIecL �O 7 Ll L{+
SINGlE FAMILY Te�+p.Power Pe!e 8 Apc�r!encnccs ri• • • • •2
HCME OWNER�BUILDER DECLARATION Sign wiih One Bronch Circuil
I hereby a�(irm�hot I om e�empt irCm IFe Co��rpc!or'S License Addiiional Siqn Branch Circuiis � ' ' � a 7 5 �
Law for Ihc followin�rn�son(5?c��on 7p91.5,Bu!�ress end
Prefes5icns Code): • � f'y�J L
❑ I,as owner of the properly,will do fhe werk ond Ihe M"sc.Condui+s 8 Conductors •�•
srructurrt is not intended cr ofiered for sole(Secrion Orher(See Comple�e Fee Schr.duleJ_ ► ��� 7'fi S
70d4,B�s�ness and Profr.ssions Code�.
CONSTRUCTIOY LENDING AGENCY
I here6y offirm ihat ihere is a conshuciion lend�nq oqency for
Ihe pericrmancr.ef ihr work for which Ihis permit is issued PERM17 FEE (Sub-iot�l) �
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
lr.ndci s Nomr.
_ PFRMIT ISSUING FEE �D
Lr.nder's A�1drr.ss � �r
I ce�iify tho�I hme read this oppl�mtion ond sta�e ihor ihe TOTAL FEE v
abovr,ini�rmaiion is correct.I og�ee�o comply wiih oll Coun�y
ordinances and S�are lows regu�a��ng Electriml wiring,ond �
hereby authorir represr.ntarive.s oi ih�s County lo enrer upon . �
Ih�abave�me� � n d properry for in5peclion purposes.
SEE REVERSE FOR EXPIANATORY LANGUAGE
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