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Home My WebLink About1781A - WORKERS'COMPENSATIONDECLARATION 76A683 APPLICA�iON .FQR ELEC7RICAL PERMIT {� cesosc�a�aoi t hereby xfticm t6at t have a cectificate ot con4ent to se�f COUNTY OF LOS ANGEtES BUILDING AND SAFETY L, insure,or a certificate of Workers'Compensation InSuranCe,or a certified copy lhereof(Sec.3800,Lab.C.) � !'olicy No. Company FON-AVPLiCANT TO�PfLt IN .. . .. J09 �J'2 d�7�y� 1,�i, SV�%r�fJ� ' New Residential Bldgs.&Poals EACH NO. FEE 11DDFE55 �'I ��n J V � Cnrtified copy is herebY tumished. ' 1&2-Family,Sq_Ft. $ — $ lacALITV ��i�/�+�Z'�,'� � OMulti•family Sq.Ft. NEARES7 h�A,r�� . .U � Certified copy is filed with the county buitding inspection Re�eDt�4 Swimming Ap01s � �� -C CROSS ST V Ir�" Q( depxriment. `�/ OWNER OR � �� FIRM NAME � �� Aate AppGcant putlets:Rec._Light�Sw.� ' MAiI . L,�.� � ' ' � Fiist 20 A��RE55 r�•��-' CERTIFICATE OF E%EMPTiON FROM WORKERS' Totat No.�� Additional CITY Ta�No. �' �Z, } COM1IPENSATION[NSURANCE PI.AN CHECK C- (This section need not be completed if the work involved APPLICAN7 ` V Lighting Fixtures Firet 20 by fhe pecmit is tor one hundted dollus ($100)or lesc.) AObRESS Toial No. Additianal _ � O � 1 Certify that in the performance of[he Work For which this CITY . Tel No. F I ermit is issued,1 shall not em lo an Fixed Appliances Not Over 1 HP I p p y y person in any manner PERMIT W so as to become subject to the Workers'Compensat3or Laws. Range_Heater_D.W.` APPLICANT a Oven _dryer_W.M._ ADORE55 Z I Det ican Top _FqU _W.H..� -- -� Hood_,fan _Other� CITY Tel No. NOT CE O APPLICANT:If,aftar maki th Certi e of Disp. _Room Air Cond._ LiCENSE OR Exemption, you should 6ecome subject [he 11'orkers' REG.NUMBER Ciass Cortlpen3aN0� pravisioRs o[the Labor Code,gOu must forth- Pawer Apparatus&large Appliances DISTRICT NO. PROCESSED SV � , with compty with such provislons or thia permit shxlt be deemed revoked. Size&Fype HP,KW,KVA,or KVA . UP to 1 Incl. �� a'u� � �� Over S to 10 IncL FlNAL (� LICENSED CONiRACTORS DECLARAFION � - �A=E `f' a VALIDATION � Over 10 to 50 Inc�. 01 I bere6y affirm that[am IicenseJ under pmvisions of Chapter Over 50 to 100 Ina P1Nal //,' � 9 (commencing with Section 7000}oE Division 3 of tAe BUsi- Over 10U gY L'��,� � ness and Yrofessions Code,and my license iv in full force and ' � effect. � Services � License Number Lie.Clau .�-2h0 Amp.Under 600 V � 201-1000 Amp.Under 600 V Contractor Date (A�er 7UD0 Amp.or Over 600 V -� �� HOMti OWNER-BUiLDF,R➢ECLARAFION Temp.Power Pole&Appurtenances 1 here6y affvm that 1 am ezempt Tcom the Contractor's Si9n wi[h One Branch Circuit License Law for the following reasun (Sec4ion 7031.5. 8usi- Additional Sign Branch Circuits �;} ��f,. •` � nessand Plnfes�ionsCode): '�` s . e.�.� Misc.Conduits&Conductors _ __..._ .._.. . __._ ..—._... .._. .. . ---�-��i<�• _ .. f..as o_wner_oL_the Pr ' �-- -...._ .. -. . . .. . npertr.��-d�-th�-woEk aod-ihe� 6ther(SeeComP�ete Fee Schedulel— structure is not intended or offcred fur sale (Section � • •G�Jr C 7044,Buainess and 1'rofeesiona Code). CONSTAUCTION LENDING AGENCY . i " "[Ei�C% i[ here6y affirm �hat there is a constructiun lending agency - Tor the periormanee of the work for which this permi[ is pERMIT FEE (Sub•Totall � Q(j �`�C p''F'� Sssued(Sec.3097.Civ.C.J� Lender's Tlame PLAN CHECKING PEE fOne-Fourth Permit Fee) Lender's Add�ess PERMIT ISSUING FEE ,S� � f �� . . . . .... .... .. . _.. ... . i certity iLa1 f have read ihis application and state that the.. TQSAI FEE. . ,� 4i ebove informallon is correct.1 agree to comply with all County oEdinances and State laK^s regulating Etectrical wiring, and hereby aud�orize repraentatives of this County to enter upon .. - - �� the above-mentioned pruperty f6t 3nspection puipose. � SEE�R£VERSE GOR EXPLANATORY LANGUAGE r'� � --�-� Signature of er ittee Date � � i �� . � � , .� } � � � �,�i'`. .._ r � O �"3 ,�+^._~. V :n�;=. �,.•. o �. U v a+ `' �c z�^ T' — m � � �' v " y v . . . c � � .. z"• 'o ` 1' _r. i ": � 3 °=� C �n,:, K i � o' «. 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