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. SEE REVERSE FOR EXPLANATORY LANGUAGE
1/�v�� &. zq 8�
�naNre of Permittee 6ste
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