HomeMy WebLinkAbout1026A (5) WORKERS'CO.•.1FENSATIONDECLARA710N 7]0019CNJ7/B] APPLICATION FOR ELECTRICAL PERMIT O
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I hpre6y afli�n ih�i I hove o certifimlc oi mnsent 10 sr.11 �E.�,w
ir�;,re,er' lce�rlicaie of Werkers'Compensaiion Insu�ante, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
a a�err;f���ePyC�'r1eof�.3800,Laeb. .)� �, ) �
Polit No. -� C pcn � L N.�[� FOR APPLICANT 70 Flll IN X7B
�Certilied cepy�s here.by furnished, New Residentiol Bldgs.8 Pools EnCM NO. F[E A��:E55 �"
/�fCertiNed copy is filed wiih i counly buil 'ng inspe•- I 8 2•Fomily,Sq.Ft. S — S IOC�LITY
ion dep rlme��. \ Mulli-fomily Sq.FI. — nEA4E5T �
1 Residential Swimmin POolq CRO55 ST.
Dale � �� A olicani •�� � O':•n���4 �
P. FI4'.1 M1N:E rY
, �Q � 9CERTIFICA E OF EXEN.PTIO FROM WORKERS' Ouilels:Rec�Li ht_Sw._ �����
I� 1 COMVENSATION i.'SURANCE � �� r•r.nR�55 C� �
Th{s��cMion need no}be com Isled if fhs work involv�d b Firsi ZO CITY ' Tel.N .lD� /�
I ( P Y Total No. Additionol
Ihv parmil is lor on�hundr�d dollors(5100)or le�s.) R?N CMECK
II cerilfy that in ttir.pe�fe�mance of�h=work ior which ihis n:��iCntit
I permit is iss�ed,I shnil nat employ ony person�n ony monner ��9hling Fi.lures Firsl�0 ADDRE55
so as io 6ecor�e s�bj^c�to iF.e.Wo�kers'Compens�tion lows.
Add�r�or+ol
I p�'e APa'Con' Tolal No. CITY Tel.No.
Fized Applioncos Not Over 1 HP pFp:•il
I NOTICE TO APPLICANT: If, oGer moking this Cerlificale ai APPUCATiCN
E:emption, you should become subje:t �o ihr. Warkers' Re^9e— Heaier_D.W. —
� C�•^pe�sn��on rrO��S�0O5 OI 1FIP IOFlO!CO(�P,VOO musl(orth- Oven —Drynr —W.M.— ADDRESS
wi!h cemply with such pro��s�ons or this permit shali be Top —FAU —W.H.—
deemed revoked. hiood —Fon —O'her_ CITY Tel.No.
LICCNSED CONTRACTO4$DECLARATICN . l'CENS�UR
I hereby offirm ihat I am I�tensed unde�provisions oi Chop�e.r 9 D�sp. — Room Air Cond. — �FG.NU.�.+BER Closs.
([ommencing wiih Sec�ion 7000)of Oivision 3 of�he Eusiness power Apparatus 8 lorge Appliances DISTRICT NO. PROCESSEO,BY � a
�nd Professlons Code,and my license is in full force a�d effect. �Q ����IC O
Size 8 Type HP,KW,KVA,or KVAR
License Number lic.Cl�ss� FINAI V
Up 10 I Incl. �
Over I to IO incl. DATE VAl1�ATiON 0
ConNac�or ' �'e Over 10 to SO Incl. l ._ V
❑ F INAL
I om eMempi under$et. Ove�50 to IOO lnc. 6Y �y,�
Over 100 4-
6.8P.C.lor�h�s reoson (n
Service.s,Swbd.,MCC 8 Paneiboards ►� (/,// `/'U � Z
Do!r.: o-'eoo Am�.U�dr.�6G0 v r !C� `7� —
Signoture. ?Dl-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Ove.r 60p V � �
Exnmption for Rrg.T.loint.Ele�t.
I SItiGLE FA':�ILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUIlOER DECLARATION Sign wi�h One P.ronch Ci�cuit
I I hereb a(firm that I am e*em i from the Con•�a:iar's License
Law 1or ihe iollow�ng reeson(Section 7031.5,B�siness and n�diiional Sign Br�n:h Circu�`s
I Professions Code�: �� C�•(7:i
p. p y ork and the Misc.Canduirs 8 Conduci�rs
I,as owner of Ihe o cr�,will do�he w , �'• e • • •;�
structure is not intended or offe�ed for sale(Settion 70-04, O'her�See Comple!e Fee Schedule)_ ' •�
Business and Professions Cod^). � • • � �.��
CCNSTRUCTION IENDING AGENCY
I hereby affirm thot ih�rr.is a cons�ruclian Ir.nding agenty for • " • � i.':'<�
Ihe performonce of�he work for whith this prrmil is iss�ed PERM.IT FEE (S�b-Total)
�Sec.3097.Civ.C.�. G�� y—(:�
PLAN CHECKING FEE
lender's Namc FER"/;IT ISSUItiG FEE ��
l�nder's Address
I te.rtify ihat I havr.reod th�z oppl�cmion and sta�=thal ih� TOTAL FEE I (,�
cbove informaiion is cc�reU.I ngree to comply with all Co�nty
� �r nces and S�a�r. lows r,qulnting Elr.ctrical wirinc�,and
hereb au�horize epresent lives of this Counly lo enier upon
the ove-me ned prop �ly ior inspection p�rposr.s.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
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