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HomeMy WebLinkAbout1224A .WChlKERS'COMPENSATIDN�ECLARATION 7fiA663 �0�8� qpp��CAT10N FOR ELECTRICAL PERMIT � � I�erel�y affirm�lhat I have a certificate of consent to self insure, GE-0o6G � I or�cErtificate ot Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ' copy thereof(Sec.380�,Lab.C.) � PoliCy No. �mPany FOR APPLICANT TO FlLL IN AO�RESS.'z,ZZ ' 1 � T I ❑ Certifietl copy is hereby furnished. � EACH NO. FEE I New Resbential B�dgs.&Pools g g LOCALfTY _��` �, � Cer[ified copy is.tiled wilh the county 6utldinp inspecGon �&2-Family,Sq.Ft — department. _ Multi-tamily Sq.Ft. �` �NF�IREST� -� � �---� � CROSS�ST. J .. ....... /�R'1C /V� � Date � �' � Appficent Residential Swimming Pools � - � -pyVNER OR� � - ��I FIRM NAME �/ � CERTIFIGATE OF EXEMPTION FROM WORKERS' putlets:Rec-.L!'.S�/L'ght�.Sw. - .MAIL GOMPENSATION INSURANGE � s / (� ADDfiESS �E�S /�rio d d f� (This section need nat he campletetl it the work irrvolved by the �` First 20 � permit is for one hundrtsd dollars 1$t00f or less.) Total No.y� Additio�l CITY u.�(,�,��( Tel.No.Q�aI I certify that in the performance of the work for which this permit PLAN CHECK ► is i55U2d,f Sh011 nOt Bmpb` an APPLIGANT / f y person in a4ry manner so as to become subject to the Workers'Compensation Laws. L'gh[ing Fixtures Fiwt 20 °Z � ADDRESS � / � Additional �.�Z,c��� ��� Tdai No. CiTY Tel.No. Date App{icant �r^ Pixed Appliances Not Over 1 HP NOTIGE TO APPLICANT: If, after making this Certificate of PEFMIT �Exemption,you shouW 6ecome subject to the Workers'Compensatfon Rarige_ Heater_ D.W. _ arPUCANi • provisions of the Labo�Code.you must�orthwith Cwnply with such Ovan_ Oryer_ W.M._ ADDRESS �s��'�J �,�S t- G�' � provisions or this�permit shall 6e deemetl revoked.�� �� � Top — FAU _ W.H._ � LICENSEO CONTRACTORS DECLARATtON Hppd— Fan _ Other_ CITY 7ei.rro,cr j�'/—�j) t1 I here6y affirm that I am licensed under provisions of Chapter �3 UCENSE Oa t (eammencirg with Section 7000!of D'wision 3 oF the Business and Disp. _ Room Air Corid. — REG.NUMeER � ��s ; %pfessiats COUe,antl my license is in full torce and effect. DISiRICF NO. PROCESSEo eY 3 Power Apparatus&�arge Appliances /� a r . Size 8 Type HP,KW,KVA,or KVAR [ � i License Number Lia Class Up to 1 Incl. FINAL � Over 7 to t�Incl. DATE � j Contractor Date VALtDATION ❑ Over 10 to 50 InG. F��� � g 1 am exempt under Sec. Over 50 to 100 Inc. BY V � B.&P.C.lor this reason Over 700 � Servicea Swbd.,MCG 8 Panel6oards / 7/� ^ € Dete: 0-200 Amp.Under 600 V � � �_! �_t� � � � Signature 201-1000 Amp.Under 600 V � � ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.MainL Elect. SINGLE PAMILV Temp.Power Pole& �� ����! ~� Appurtenances � HOME OWNER-BUILDER DECLARATlON Sign with Ona Brarich Circuit �}• • • e .� � 1 hereby af(irm thaY I am exempt from the Contractor's License Law tor the following reason(Section 7037.5,Business and Prcfessions Additional Sgn&anch CirCuits Coae): I • •4 5�0 � q! I,as owner oi the properfy,will do the wak ard the structure Mise.Conduits&Conductors • o ,4.^.. .-;_� is noi intended or otfered for sale(Sectian 7044,Business Other�See Complete Fee Schedule)_ � � and Rofessians Code�. �E"-2�i'—�ij CONSTRUCTION LENDING AGENCY I hereby aflirm that there is e construction lending agency for the perFormance of the work for which this permit is issued(Sec.3097, pERMIT FEE (Su6-Totaq � p� Civ.C.). PLAN CNECK�NG FEE Lender's Name , PERMR ISSUING FEE Iv Lentier's Address . . . . ... . .- . . - . - . I certity that 1 have reatl thls appiication and state that the above 70TAL FEE � - _ . .. .... ..... .. . . .... ....... . ...... .. . .. . . . .. .. . . . .. infwmatan is correct.1 agree to wmpiy with all County ortlinaices � �- � � and State laws regulating Electrical wiring,and hereby autFwrize represenfatives of this Courdy to erAer upon the above-mentioned � - property for inspection purpo3es. 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