HomeMy WebLinkAbout1427 (8) WORKERS'COMPENSATIONDECIARATION ���p� ���g� qPPLlCATION FOR ELECTRICAL PERMIT
I hereby affirm thaf i have a certificate of consen�lo s If// �'�j�'
insure,or a terilfico�e of Workers'Compensa�ion lyf�anc�/ ,� COUNTY OF LOS ANGELES BUILDING AND SAFETY �`
or a certifLied copy thereof(Sec.3800,Lab.C.) 6 �� 1�� � �T b LI
P❑olicy No?��ompany�f�P�� J FOR APPLIGN7T0 Flll IN �OB
Cert�fied co is here6 f�rnished. EnCH NO. FEE Aooaess Oq E.Q1SD�1L '�U/.�
PY . Y _ .. . . ._ . New Residentia{Bldgs.&Pools .. - �
et&2-Famil fi. s = 5 LOCALV7Y D�A .,�� .�4Q
Certified COpy is filed with tha tounly building inspec- Y.SQ�
tion depa.tmanf. . Mul��-fomily Sq.Ft. NEAREST
�2 ���" Residenlial Swimming Pools OWNER OR ���� � ���LS �D •
Da1e Applicant FIRM NAME W•LYQ� CO.
` CERTIFICATE OF EXEMPTION FROM WORKERS' MA�L /�
Outlets:Rec_Light_Sw._ AOORESS
S COMDENSATfON INSURANCE P.O. �Ll I
Fint 20
( (Thia�«t�on m�d aet b�eompk��d H H�e work inrolv�d by Total No. CITY iel.No.b� j
( Nw pemEG Is Eor ww kundred doflan(SI00}or IessJ Addi�ional 6td Oa�•`��i00 �
1 cer�ify ihot in tha peho�monce ot the work}or which this p�ppN��TK
permil is iss�ed,7 ahafl not emplpy any person in any manner
so as to become su6ject to the Workers'Campenmtion Laws. Lighting FixWres First ZO ADDRESS �
Tofal No. Additional
CITY Tef.No. �
Date �pplitant Fixed Applionces Not Over 1 HP PERMIi
. NOTICE TQ APPIICANT: I€, afler moking this Certificate of qppLlG4Ni G .
E:emption, you should become subject to the Workers' ' Range_Heater_D.W. _
Compensation provisions of ihe Labor Code,yo�m�st forih- Oven _Dryer _W.M.— ADDRESS 0
with comply with such provisions or ihis permit sMll be iop _FAU _W.H.� �
deemed.evoked. Hood �Fon _Other_ CIN a�� Tel.No. ,�
IICENSED CONTRACTORS DECIARATION �
I hcv�by affirm thot I am licensed under provisions of Chopler 9 Disp. _Room Air Cond. — R����ER �4f� Ioss, C^�Q
(mmmencing with Saction 7000F of Divisinn 3 of ihe Business DISTRICT ND. OC BY R �
ond Professipns Code,and my license is in f�ll force and eHed. Power Apparatus 8 Large Appliances � #
Size 8 Type HP,KW,KVA,or KVAR � V �
License Num6er Lic.Class ��1 O Up to 1 lncl. fINA1 fY j
P ��,� Over i ro t01nd. DATE �=/le� ��5� O j
Contract �l• �����t_Date r�s�� VAUDAAON I—
� � Over10to501nc1. FINAL '�"/Y�7 W �
i am exempt under Sec. Over 50 fo I00 Inc. BY �- r:. 4 :.a .n j r n.� �
Ove�700 N '�
B.&F.C.for Ihis reoson , y �i ;:, z
Date: Servites,Swbd.,MCC&Panalboards � � _ �� �
0-200 Amp.Under 600 V i r �! i -� , �
Signature � 201-1000 Amp.Under 600 V 4
Over 1000 Amp.or Over 60p V � 3
� Ezemption for Reg.Maint Elect. t yµ��p�f
SINGIE FAMILY Temp.Power Pole 8 Appunenances
HOME OWNER-BUILDER DECLARATION Sign with Ona Branch Circuit
I hereby aHirm thar I am exempt from the Contractor's License ,qdditional Sign Bronch Circu�ts
law for the following reason(Settion 7031.5, Business ond 'g yu� a0�
Professions Code�: �
❑ I,as owner oF Ihe property,will do ihe work and the Mist.Conduits&Conduttors �
strudure is not in�ended or offered for sale(Setlion Other(See Complete fee Schedule)_ �
7044,Business and Profeseions Code).
CONSTRUCTION IENDING AGENCY ,
I hereby affirm thol there is a mnstroction lending ogenty for ,
�he performance of the work for which Ihis permit is issued PERMIT fEE (Sub-Total)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
lender's Nome
PERMIT ISSUING PEE I O Q
Lender's Address
I terfify lhat I have read this applica�ion and stafe thot the TOTAL FEE �Q�•S0 -
above infwmation is corred.I agree m comply with all Couniy -
ordinonces and State laws regulating Electrical wiring, ond
hereby authorize representotives of this County io ente�upon r
the obov - eni" ned properiy for inspedion purposes. �
SEE REYERSE FOR EXPLANATORY LANGUAGE �
� /s-3-�S' " ]
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