HomeMy WebLinkAbout0891A (4) ' 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
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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
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