HomeMy WebLinkAbout1740A WORKERS'COMPENSAT[ONDECLARATION 78A663 APPLiCATION FOR ELECTRICAL PERMIT I
CE�O6G(2-80) /'� I
I hereby aftirm thut I have a certificate of consent to se�e COUNTY OF LOS ANGELES BUILDING AND SAFETY �u
insure,or a certificate of Workers'Compensation Insurance,or
a certifiedL copy thereof(Sec..!3800,Lab.CJ
�.��7 WC ��50�. i•�� 1 FDR APPLICANT TO FILL IN �pg r� J� r
� Policy No. Company �'r e-�n�1$ � ��'++� ADDRESS �d�� .{�
=tie,, 4`� New Resideniiat Bldgs.&Pools EACH NO. FEE e
� Certifled copy is here6y furnished. 1&2•Family,Sq.Ft. $ — $ LOCALITY q
� Certified cu y �� P Mul4i-fyfTlily Sq.Ft. — NEAR S7
py a filed with the count buildin �ns ection CROSS ST
department. Residential Swimming Pools
QWNEROR �+ }� �0. O�
Ll FIRM NAME Y IJ
Datz�'�J��Applicant Outlets:Rec�.�Light�Sw. � MA�L !
�y� First 2� t Fl�ORESS ��}T��-
CER7IFICATEOF'EXEMPTION FROM WORKERS' Total No._3�� Addrtional � CITV Tel No. Y
COMPENSATION INSURANCE
PLAN CHECK 2
(I'his seetion need not be completed if the work involved ��j 6 APPLICANT V
Lighting Fixtures First 20
by tlie permit ia fot one hundred dollars ($100)or less.) ADDRESS �
Total No.� Additional � \C5
I certify that in the pertormance uf the work for which this CITY 7e1 No. �
ermit is issued,I sha11 not em Io an Fixed Appliances Not Over i HP k-
P p y y person in any manner PERMIT c b�(�o r L—)e.LI ,c C O W
so as tu becnme subject to the Workers'Compensation L�ws. flange_Heater Q.W. APPLICANT t'� a
Oven _Oryer_W.M._ ADORE5S �t� �i'j �a�'i�Q PI a�� �
Uate Applican[ Top _FAU _W.H._ a1 _
Hood—Fan _Other_ ��TY `q/�� Te1 No.7�7-9�'r�'3�
NOT[CE TO APPLICANT:If,after making this Certificate of� Disp. ._Room Air Cond._ LICENSE R s�u t 2
Exemption, you should bacome subject to the Workers' REG.NUMBERj-!� �l 3 Class C 1(� �
, Compensation provisions of the Labor Code,you must fwth- power Apparatus&Large Appliances �ISTRICT NO. PROCESSED BV
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR �� �+(�(\ � `
deemed tevoked. �!`
Up t0 7 Incl. FINAI �
Over t to 10 Inci. oare VALIDATION l
LICENSr'.D WNTRACTORS DECLARAT[ON Over t0 to 50 Incl. . q
1 hereby affirm that I am licensed under pravisiuns of Chapter Over 50 to 100 Inc. B�NAL j
9 (commencing with Sec[ion 7000)ot Division 3 of the 8usi- Over 100 �O �' �
ness and Ptofessiuns Code,and my license is in full force and
effect. $ervices �
License Num6er 49 /1�. Lic.Class � �� 0•200 Amp.Under 600 V �
207•1000 Amp.Under 600 V
Contructor Date � ` �"g�, Over 1000 Amp.or Over 600 V ;
HOME QWNER•BUIL R nF,CLARATION Temp.Power Poie&Appurtenances j
€I hereby aff'vm that I am nxempt Gom the Contrac[or's Sign with One Branch Cireuit �
License Law for the following reason (Section 7031.5, Busi- Additio�al Sign Brench Circuits
ness and Professions Code):
Misc.Conduits&Conductors
� l, es owner of the property,wiil do the work and the pther(See Complete Fee Schedulel—
structure is not intended or offered fur sale (Sectiort
9044,Husiness and Professions Code).
CONSTRUCTION LENDING A6ENCY
I hereby affirm tha� there is a construction lending ugency � �� •I Q O A
tor the performance of the work for which this permit �s pERMIT FEE (SutrTatall
issued(Sec.3097,Civ.C.). #� • • � .�
Lender's Name pLAN CHECK WG FEE (One-Fourth Permit Fee) �
Lender's Address � • •E 2 9�
PERMiT ISSUING FE� - ,
• • •6290=
I certify that I have read this application and state that the TOTAL FEE l� �
above informatian is correct.t agree to comply with all County a 3,�4-8 2
ordinances and State laws regulating Electricat wiring, and
heroby authorize representatives of this County to enter upon �
the above-mentioned property tor inspectiun purposes. SEE�REVERSE POR EXPLANATORY LANGUAGE
u�or,r��'1<c�n,. _3-��— -- - ---- - — — — -- —
Signature of Permictne�— Date � (
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