HomeMy WebLinkAbout1701A WORKERS'COMPENSATION DECLARATION �� ,�,81 APPLICATION FOR ELECTRICAi. PERMIT
I hereby affirm thal I have a certificote of consent to self �'�G �
insure,or o rertiFlmte ot Workers'Compenwtion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified wpy thereof(Sec.3800,Lab.C.)
P�ol�icy No. Compony� FOR APItiCANT TO F{Ll fN � ' JOB - � ^ '
Ce�frfied copy is hereby f�mished. EACH NO. �E AODRE55 `'fF� L//LLs �
New Residential Bldgs.8 Pouls ��
� Certified copy is filed with the county 6uilding inspec- ��2-Family,Sq.Ft s — S IOCALI �� p-�� , �°M,� `{i
tion department. Multi-famlly Sq.Ft. — NEAREST
CROSS ST. �
Residential Swimming Pools
Da�e App4icont OWNER O .
FIRM NAME L �LS
CERTIFICATE OF EXEMPTION FROM WORKERS'
Outle�s:Rec_Light`Sw._ �''v'�� '�/
COMPENSATION�NSURANCE AWRE55 �v /�
First 20 �
(This�ecfbn nwd not bv eompfvf�d ff tha werk invoirad b� UTY � �y� .No.7�� �
1hQ pormif i�for orw aund�od do{lars(s100)or lass.) iotal No. Additional _
PLAN CHECX �
I certify fhat in ihe performance of the work 4or which ihis APPtiCANT
permii is iswed,I shall�ot employ any person in ony manner
w as fo become su6ject to Ihe Workers'Compensation Laws. ��gMing fi:rures firsT 20 ADDRESS
Totol Na. Additional
� � CITY Tel.No.
Da�e plicont ' fixed Appliances Not Over i HP ���T
NOTICE T APPLCAN-� If, after making ihi Certificate of App���NT�-(, ��t(/ JOC
Exemption, you sho�ld become subject to the Workers' Range_Hea�er_D.W.—
Compensation pro�isions of the Labor Code,yau must forth- Oven _Oryer _W,M.— ADDRE55 �'�"� L GO/}�-//1/f'j–
with compfy with'such provisions or this permit shail be Top —FAU —W.H.—
deemed revoked. Hood _Fan _Other— ��Fr 6/YI> �/j/�� No. =�7
UCENSED CONTRACTORS DECLARATION ��N��
I he�ab offirm Ihot l am licenaed under P Disp. �Room Air Cond. _ LZ��6 C�� �,3 R
Y provisions of Cha ter 9 REG.NUMBER �
(commencing with Section 70p0}04 Division 3 of the 8usiness power Apparatus 8 Larga Applionces DISTRICT NO. PROCESSEDgy �
and Profeisions Code,and my license is in full force and effect. � A �c/ ���/ � �
3 y��� Size 8 Type HP,KW,KVA,or KVAR U vl 0
ticense Number Lic.Class�_ Up fo 1 Incl. fINAL ,, V
Over 1 to 10 Incl. DATE �, p�
Controctor ate Z y .�� � YALIDATION �
Over 10 to 50 Ind. f�NAL ( V
��am e�emp�under Sec. Over 50 l0 100 Inc. BY 1 � y�
B.&P.C.for this reason Over iW ' �'�\��`�{��� y
� Servires,Swbd.,MCC&Panetboords = �
Da1e: –� 0-20D Amp.Under 600 V �
Signature L 201-}000 Amp.Under 600 V - ��� 7 Q� A
� Over 1000 Amp.or Over 60p V �� � � � �2
Exemp�ion for Reg.Maini.Eleci.
SINGLE FAMiLY Temp.Power Pole&Appurtenances � � � • •�rJ.�Q �
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm thm I am exemp�from the Controctor's License • a a G j,5 Q�=y
Law for the following reason(Section 7037.5, Business and Additional Sign Bmnch Circuits �
Professions Code): G 2,2 3�8 4 �
� 1,os owner o4 the ro r Misc.Conduits&Conducfors
p pe ty,will do the work and the � �
struc�ure is not intended or offered for sale (Section Oiher(See Complete Fee Schedule)_
7044,Business and Professions Code). .
CONSTRUCTION LENDING AGENCY �
I hereby offirm that there is a tonsrruction lending agency for �
the performance of the work far which ihis permit is issued PERMIT FEE (Su6-Toto!)
(Sec.3097,Civ.C.}.
PLAN CHECKING fEE (� �' `
Lendels Name a S� �
PERMIT ISSUING FEE
lender's Address
I certify that I have read this application and stafe Ihat the TOTAL FEE
above information is carrect.I agree lo comply with all County f
ordinances and State laws regulating Eleciriml wiring,'and �
hereby authorize representalives of ihis County to enter upon i
the above-mentioned properry for inspecfion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatwa oS Pe�mitree Date �
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