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HomeMy WebLinkAbout0891A ' WORKERS'COMPENSATION DECLARATfON CEA808G '°'81 QPPLICATION FOR ELECTRICAL PERMIT {� � i hergby affirm that I have a ceridicate of cOnsent to selt insure, a a certificate of Workers'Compensation�nsurance,or a certified COUNTY pF LOS AIJGELES BUILDING AND SAFETY u copy therenf(Sec.3800.Lab.C.) PoliCy N0. CORlpdfly FOfl APVLICANT TO FlLL IN ' JOB ADDRESS . •�.�• � � .. � CerGfied coDY is hereby furnished. New Residential 81dgs.8 Pods -�ff�- NQ FEE . � Certified copy is filetl with the county 6uiltling inspection 1&2-Family,Sq.Ft. $ — $ LDCALITY �� department. - � Multi-family Sq.R. — N�aaeSi CROSS 5T. t - - Residential Swimming Pools OWNER OR ♦/ r �ate MPliCant .. . . . . . .. FIRM NPME � C�`e� :l�G L� GER7IFICATE OF EXEMPTION FROM WORKERS'�� putlets Rec�light�Sw.� � �� COMPENSATION INSl1fiANCE .. � ADDRESS .A�'•E (This aectbn need nat be completed if the work irndved by the First 20 , permi!is iw One_hundr¢d d0118fS(5100)w IesSJ , Total No. Addiiional -. _... _-CfTY. . . . ... Tel.No. I certify that.in the.per�ormar�ca of the.work.tor which Shis permit PLAN CHECK � �issued,I shall rrot empby any person in any manneu so as to APPLICANT f become subject t ihe Workers'Competuation Laws. �� ' ting Fixiures First 2o ADpRESS � � � Totei No.� Additional --�--. . __ _-_. Date � F APW�cant : � . . ... . CITY . . . . . .. . -..-�- Tel.No. � NOTICE Q.APPLICANT If a(ter makirg � Certificate of Fixed Appliances Not Over 1 HP PERMIi Exemption,you should become subyect to the Workere'Gompensation Range_ Heater_ O.w. _ '��T ��� �✓ r i provisions of the Labvr..Gode,.youmusttorthwlth-.qomplY.with such Oven_ Dryar_ W.M._ ADDFE55 - � L��/S � ' .provisions or this permlt shan be daemed revoked. � Top _ FAU _ W.H._ p�/ � LJCENSED CANTRAGTORS DECLARA7lON. Hood—Fan — Other_ ��Y �� ��NO� 6 .00 I hereby affirm thaE I�am licensed under provisions of Chapter 9 uCEtdSEoe O �n DisO. — Room Air Contl. _ f�G.FIUMBER r Gass. (comrr�encing wRh Section 7000)of Divisivn 3 d.the Busirie9s ard Rofessiws Code,and my licensa is in fuq torce aM etfect po�r ApparatLLs&Lar�e Appliances dSTRiCt NO. - PROCE D 6Y � L� Size&Type HP,KW,KVA,or KVAR �� Q � License Number !�9 �.�� Lic.Class � � Up to 1 Incl. FINAL U � Over 1 to t0lncl. DATE /' r._Y� � � YALIDAT{ON Contracta • Date Over 10 to 50 Incl. F��� �� � � ❑ 1 am exempt under Sec. Over 50 to 100 Inc. gy � W 8&P.C.for this reason Over 100 N k Services,Sxbd.;MCC 6 Panel6aards � � Date- 0-20�Amp.Under 800 V � ! Signatura 201-1000 Amp.Under B00 V � � ❑ � Over 7000 Amp.or Over 600 V r : Ezemption tor Reg.PAaint.Elect. � ��� ��� SINGLE FAMILY Temp.Power Pole&Appurtenances 3 HOME OWNER-BUILDER DECLARATION Sign wiih One&anch Circuit � f hereby aifirm that I am exempt irom the Contractrn's License Law For the foliowing reason�Section I03 L5,Business and Rofessions ���pnal Sgn Brancn Circuits � CodeY • ❑ ���� MSc.�Conduits�&�Ca�x;tors � � - - � -- <0 a 9,1 A j I,as owner of che property,will do the wak and the s[rucfure ���(�Compiete Fee Schetlule)_ j is not intended or offered for sale(Section 7044,Business � #• • • • •`� ; arM Protessions Gode). 3 CONSTRUCTION LENDING AGENCY � -� � ' ' I Y,J U I I hereby affirm that there is a construction lendi�agericy for the • , a ' `;:J V� � parformance of the work for which this permit is issued(Sec 3097, pERMiT FEE (Sub-Totaq Civ.C.1. Q�.� 9„�7 PLAN CHECKING FEE � I Lentler's Name � PERMCT ISSl11NG FEE I Lender's Add�ess I certify that t have read this apPlicatWn and sCate that the above TUTAL FEE 9 (] information is co�r�ct.�agree b comply with all Courrty ordinances and Statc laws regulatirg Electrical wiri _and hereby autFrorize represeMatives of this County to en upo t bove-mentioned praperty tor inspection• r SEE REVERSE FOR EXPIANATOHY LANGUAGE . � Signature of rm' e ate .. T � y ��=o = y � m N �� .—. .O . 'p �4jy `N � , . . �/a -� � � � '� � '_" A t.l 'Oc ' �_�p� �'v) �;Cry � '� . . � . " C tC � C�q in �V�j2��• �� �3 � �' Nc � ' . ' . � . ' +U v� {2. Qj , C „ y ,1- U'�y� O � .� . . . . .J �y t6 � ��' C� y� U . 6 _ Y.fn i'S ,C_�O,N i d N y N � Q� ���O'� �p � � 4 .0,.�'_�' 6, y . ' 7 p ,. 2 °v.t��� o amr� p �.': $i�.0� 5� i p o �' O p c� � N �� �a �@��'�,g� �� � � � � vch .c�_a �m � �rn :�i� !3 �n � `�V � 'o' ,+n_ � . .. J y;� � �i�� r � � ��' y o �� � � � � �. 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