HomeMy WebLinkAbout1590A (9) WORKERS'CO.M?ENSATION DECIARATION ��A�,� �o,e� qpp�ICATION FOR ELECTRICAL PERMIT �
I hereby affirm that I have o cr.riH�caie oF consem to self fE-B06G
insurr.,or o certilicoie of Worke�s'Compensoiion��su�ance, • COUNTY OF LOS ANGELES BUILDING AND SAFETY
o�n cerhfied copy ihercof(Se�.9800,Lob.C.)
�Cy No. Compa�y FON APPl1UM TO FILL IN JOB 7 G
Cer�lfied copy is hereby(�rnished. New Res�den�iol Bldgs.8 Pools EACH NO. fEE �DDRCSS �7 �L.
� 1 8 2-Famil � /
Certitied copy is f�led with the tounty building inspec• Y,Sq.FI. _ — f IOCALITY �aJ �,�' �'d� q/
tion department. Mulii�tamily Sq.F�. — NEaaCST
GRO55 5T. QQ;r . PC�' M
Do�e qpP�;�a�� Rasidanl�ol Swimming Poois D'+vr�ER DR
. i4GMNAME bII�� C• (�
CERTIFICATE OF EXEMGTION FROM WORKERS' pu�lers:Rnc_Light_Sw._ MA't .�7 n ��f
COMPFNSATION INSURANCE F.Is'� ADDRESS s-��!�O E.(C /�
(This��cilon nssd nof ba tomplafed il fh�work Involv�d by 7orol No. Additionol CITY `�y� �^ Tel.No. �—y}%�3
�h�parmif i�fer ona hundred dollan(SI00)or las�.) �
1 certify�tior in the performance of�he work for which ihis RAN CNfCK
APPLICANT
permi�is�ssved,I shall no�employ ony pr.rson in nny mnnnPr
so as to becnme subject fo rhe.Wo�kers'Compensation Laws. lighling FiKiures First 20 ADDRESS
� Tatal No. Additianal
K � CITY Tel.No.
Da�e epplicnnt Fixed Applian�es Not Ovr.r 1 HP PFRMiT
NOTICE TO APPIICANT; if, o(r moking Ihis Certificate APPLICANT ,4� C' G tI�'�
E>empiion, yov should beco subjecl fo the Wo�kers' Range_Henler_D.W.— �
Compenso�ion prov�s�ons of ihr.lobor Code,you mus�for�h- O�en _Dryer _W.M._ ADDRESS 'j�j�o1� E �
i wi!h comply wiih such provisions or this permit sholl be Top _FAU —W.H. ��,
i deemed re�oked. Hnod _Fan _Other.� CITY � Tel.No. 6/-- �
i LICENSED CONTRACTORS DECLARATION
Disp. —Room Air Cond. — � ! ���N��R Closs.
I hereby a(li�m tnnt I om I�censed undr.r provisions oF Chapter 9 REG.t�UhM1BER
(tommencing wiih Sectlon 7000)of Division 3 of�he Business power Apparatus 8 largr,Appliances DISiRICT NO. PROCESSF BY �, �
ond Pro.essions Code,and my license is in Full forcr,and affxtl.
Sire 8 Type HP,NW,KVA,or KVAR l � � ,t���'`� �
l�cense Numbr,� lic.Closs V
Up to I Incl. FINAL I I
Conrrvcror Date Over 1 fo 101nc1. DATE '���::�1�L� VALIDATION �
Ovor 1010 50 Incl. FINAL O
❑ I nm erempt under Se[. Over 50 to IOO lnc. BY 1��1`�`�, � '
B.&o.C.fc�rhis reason Over 100 y
Services,Swbd.,MCC 8 Ponelboords , _
�O�n' 0-200 Amp.Under 600 V
Signowre 401-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
E.emption(or Reg.Ma�ni.Elecr.
$INGIE FAMILY Temp.Power Pole 8 App�rtenances
HOME O`NNER-BUILDER DECLARATION S�gn wi�h One B�onch Urcuil
I hereby n!firm�hof I am e.empl frem ihe Controc�or's License
Law!o.!�>fel�o•:,ing r��s�n(Set!:on 7031.5,°usir.rss and Additionol SiGn Branch Circuits ��i ��.rJ n
Professions Codc): � � v
� I,as owner af Ihe properly,will do the werk ond ihe Misc.Condui�s 8 Conduc�ors . ° • • ° °(
shuc�ure is ne�iniended or offered for sale(SeUion Other(See Complete Fee Schedule)_ ► � n o � �,O O
I70�•1,Busir.ess and Professions Code). � . ^ _
I CONSTRUCTION IENDING AGENCY ` � �5 G O i�
I hereby nffirm thnt therr,is a cons�ruction lending ogency(or �,�.� f)�&�!
thr.performoncr.of�hr,work for which this permil is iss�ed PERMIT FEE (Sub-To��l) � ,��
I (Sec.3097.Civ.C.�.
PLAN CHECKING FEE
I Lender's Nome
PER.MIT ISSUING FEE /C JQ
lender's Address
I certify ihai I hnvr.rrod ihis opplirn�ion nnd stoic thot ihe TOTAL FEE ��Cl
I above informaiion is corrru.I egree+o comply with all County
i ord�na�ces and Statn laws regula+ing Electricnl wiring,and
hereby author�rF re��r.senialives of ih�s County to enter upon
�he a6ove.-mr.���oned prope�tv for inspr.ciion p�rposes. SEE REVERSE FOR E%PLANATORY LANGUAGE
� r/Lc�.� ('• .���n: F��7 I �
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