HomeMy WebLinkAbout1533A (8) WORKERS'COMPENSATION DECLARATION ,76A663
�, CE$06G(2-Sf�� APPUCATI4N FOR ELECTRICAL PER�Ii1i �
1 hereby affirm that I have a certieicate ot'consent to se�t' COUNTY OF LOS ANGELES BUILDING AND SAFETY
_ insure,or a certificate of Workers'Compensation lnsurance,or � �
a certified copy thereof(Sec.3800,Lab.C.) '
FOR APPLICANT TO FILL IN J09
� Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADORE55 z��Z S �1drJG�G�I+-�
� Certified copy is hereby furnished. i&2-Family,Sq.Ft. S —. $ LOCALI7Y ��,�.���,r� ���
Multi-family Sq.Ft. NEAR ST
� Certified coPY�s Piled with the county building irtspection CROSS ST
department. Residential Swimming Pools OwNEF OR �
FIRMNAME �H fClf I
Date Applicant Outlet5=Rec.._Light_Sw._ ADDRESS �3�/
First 20 ���N
CERTIFICATE OF EXtiMPT10N FROM W'ORKERS' ToWI No. Add�tional CITVD��V � Tel No7//� �f/ /r
COMPENSATION[NSURANCE
(Ttua secGon need not be completed if the work involved APPLICANTK U
by tlie pezmit is for oue hundred dollars(5100)oc leca) Lighting Fixtures First 20 ADDRE55
Tota�No. Additional ¢
1 certify that in the performance of the work for which this CITY Tsl No. �
permit is issued,[shall not employ any parson in any manner Fixed Appiiances Not Over i HP PERMtT U
so as to 6ecotne subject to[he Workers'Compensation Laws. Range_Heater_D.W._ APPLICANT W
�J ����� Oven _Dryer_W.M._ ADDRESS Z .
Date r����QAppiicant Top _FAU _W.H._ CITY Tal No.
Hood—Fan _Other—
NOTECE TO AYPLICANT:[f,atter meking this Certificate of Disp. ._Roam AirCand._ LICENSE OR .
Exemption, you shonld become subject to the Worken' REG.NUMBER Class
Compenrytiort provisiorta of the Labor Code,you must forth- Power Rpparatus&Larg9 Appiiances DISTRICT NO. PROCESSE BV
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or K VA /p �
Up t0 1 Incl. �
Over i t0101nc1. FINAL
LICENSEDCONTRACTORSDECLARAT30N DATE f�� yALIDATIQN
Over 10 to 50 Incl. �� ��
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 700 Ina FiNAI
9 (commencing with Section 7000)of Division 3 of the Busi- Over 10Q B . � �
ness and Prnfessions Code,and my ticense is in futl force and L �
effect. . Services
License Number Lic.Class 0•200 Amp.Under 600 V �
201-1000 Amp.Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION T¢mp,Power Pole&Appurtenances �
I hereby affirm that 1 am exempt trom the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- �ditional Sign Branch Circuits
ness and Professions Code): -
Misc.Conduits&Conductors .
� [, as owner of the praperty,will do the work and the Other�See Complete Fee Schedulel—
structure is not intended or offered for sale (Section
7044,Business and Professions Cude).
- CONS'IRUCTION LF.NDING AGENCY �
I hereby affirm that there is a wnstruction tending ngency
' for the performance of the work for which this permit is pERMIT FEE (Sub-Totap
' issued'(Sec.3097,Civ.CJ.
� Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) � – - •
� =- IJ.`v'P.
I Lender's Address pERMIT ISSUING FEE � (J
i i r c • c a�
� 1 certify that I have read this application and state that the TOTA4 FEE
� e6ove informa[ion is correct.I a ree to com I with all Count � � ` " � ��C'A�
i 8 PY Y
^rdinances and Sta[e lews regulating Flectrical wirtng, and
-�-'�uize representatives of this County w enter upon ' - ' = i i•�'t,�c
" ned propertY for inspection purposes. SEE�REVERSE FOR EXPLANATORY LANGUAGE �)j�,j �;c,�
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