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HomeMy WebLinkAbout1781A (10) - WORKERS'COMPENSATIONDECLARATION 76A683 APPLICA�iON .FQR ELEC7RICAL PERMIT {� CESO6G(��801 t hereby xftirm t6at t have a certificate ot con4ent to se�f COUNTY OF LOS ANGELES BUILDING ANp SAFETY u insure,or a certificate of Workers'Compensation InsuranCe,or a certified copy lhereof(Sec.3800,Lab.G) � !'olicy No. Company FON-AVPLiCANT TO�Fftt IN .. . .. JOa �7�d_l.�y 1,�i, �V�%r�(7� ' N¢W Residential BIdgS.&POOIs EACH NO. FEE ADDFESS 4 ��n/ L � Certified copy is herebY fumished. ' 1&2-Family,Sq.Ft. $ — $ IOCAUTV ��i�/�(T'','� � OMulti•family Sq.Ft. , NEAREST h�A,r�� �. .U � Certified copy is filed with the county buitding inspection Res eDt�4 Swfmming Apols � �� -C CROSS S7 V Ir�" Q( depxriment. `�/ OWNER OR � �� FIRM NAME � �� � Aate App{icant Outlets:Rec._Light 1 Sw.� ' MAiI . L,�.� � ' ' � Fiist 20 A��qE55 r�•��^-' CERTIFICATE OF E%EMPTiON FROM WORKERS' Tota1 No.'� Additional CITY Ta�No. �` �Z, } COM1IPENSATION[NSURANCE (This section need not be completed if the work involved APPLICAN7K ` U Lighting Fixtures Firet 20 by fhe pecmit is tor one hundted dollus (SI00)os lesc.) AodAEss Toial No. Additianal _ � O � 1 Certify that in the performance of[he work For which this GTY . Tel No. F I ermit is issued,1 shall not em lo an F1xed Appliances Not Over t HP I p p y y person in any munner PERMIT W so as to become subject to the Workers'Compensatior Laws. Range_Heater_D.W._ APPLICANT a Oven _dryer_W.M._ AOORE55 Z I Del ican Top _FqU _W.H..� - -� Hood_,fan _Ott3er� CITY Tel No. NOT CE O APPLICANT:If,aftar maki th Certi e of Disp. _Room Air Cond._ CiCENSE Ofi Exemption, you should 6ecome suoject [he Workers' REG.NUMBER Class Conlpen3aNOn pravisiosis o[the Labor Code,cOu m�st forth- pawer Apparatus&Large Appliances DISTRICT NO. PROCESSED SY t with comply with such provislons or thia permit shxlt be deemed revoked. Size&Fype HP,KW,KVA,or KVA . Up to 1 Incl. �Q a��'`��� I FlNAL �� Over S to 10 IncL �AiE (� � LICENSED CONiRACTORS DECLARATION � - `f' a VALIDATION Over 10 to 50 Inc�. 01 I 6ere6y affirm tAat f am IicenseJ under provisions of Chapter Over 50 to 100 Ina F1NAL //,' � 9 (commencing with Section 7000}of Division 3 of the Basi- Over 100 gY L'���V,� � ness and Yrofessions Code,and my license is in full force and ' � effect. � Services � License Number Lie.Clau .0-200 Amp.Under 600 V � 201-1000 Amp.Under 600 V Contractor Date tA�er 7UD0 Amp.or Over 606 V -� �� � � HOME OWNER-BU[LDF,R➢ECLARAFION Temp.Power Pole&Appurtenances I here6y affvm that 1 am ezempt Tmm the Contractor's Sign wi[h One Branch Circuit License Law for the following reasun (Sec4ion 7031.5. 8usi- Additional Sign Branch Circuits �_} ��f., •` � � ness and Plnfes�ions Code): i Misc.Conduits&Conductors _ __..._ ..,.. . __ .._._... .._. .. . ---�-��i:�• : • e..."L?_ .. . � f..as o_wner_aL_the Prnperty.��uill.At�...tfi�-woEk aod-the� . .-- -.. . -. . .. . Other(See Complete Fee Schedule)— structure is not intended or offcred fur sale (Section � • •G�Jr C 7044,Buainess and 1'rofeesiona Code). CONSTRUCTtON LENDINL'AGGNCY . i " "[Ei�C% �'t here6y affirm �hat there is a consvuctiun lending agency - Tor the periormanee o( the work for which this permi[ is pERMIT FEE (Sub•Totall � Q(j �`�C p''F'� 5ssued(Sec.3097.Civ.C.J� Lender's Tlame PLAN CHECKWG PEE fOne-Fourth Permit Fee) Lender's Add�ess PERMIT ISSUING FEE ,s� � f �� . . .... .... .. . _.. ... . i certify 1Lai 1 have read ihis apptication and state that the.. TQSAI FEE. . ,i �r � ' ebove information is correct.1 egree to cumply with all County oFdinances and State law^s regulating Etectrical wiring, and hereby aud�orize repraentativzs of this County to enter upan ,. - - �� the above-mentioned pruperty f6t 3nspecti�n puipose. � SEE�REVERSE GOR EXPLANATORY LANGUAGE r'� - ---�-� Signature of er ittee Date � I i ��: ? f' � r �i'~ � ' . y� � G c.~.u �j.,_, � +' p . C..) 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