HomeMy WebLinkAbout1822A WORKERS'COMPENSATION DECLARATION 76A663 t0ie1 ppp��C�T101V FOR ELECTRICAL PERMIT � �
i hereby affirm that I hove a certificate of consent to self �E-�
insure,or a certificate of Workers'Compensation Insuran�e, �� �OUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy r�ifjgrf,cQp t e o ��n 8�La��nn FOR APPIICANT TO FILL IN !OB y �j�� ('�,�, Ia
����
u L AOORE55 �O(� �� •��{�{ V I ilV C.�
� Certified copy is hereby furnished. New Residential Bldgs.& o �CH NO. FEE , L
�Certified copy is filed with the county building inspeo �8 2-Family,Sq.Ft. — ; ��'��TY '7
tion deparfinenr. Mul1i-family Sq.Ft.� — NEARE57
�7 �.�a CRO55 ST,
Date�L���Apptkant���1 v ���G Residential Swimming Pools � OwNeR Oa '�e /�,���^� '�
FIRMNAME �C.l LkJY 1-�I r�C O�
CERTfFICATE Of EXEMPTION FROM WORKERS' � OuNers:Rec_Light_Sw._ �"�'0'�� q�
� COMPENSATION INSURANGE -- first 20 ADDRESS�I Q vl r ���
(T61�wcflon naod noT feo complNod if Tha xwrk inrolwd b� Total No. OTY Tel.N .
f6o pormit is for ona hundwd doflan{=100)or las�.) Additional �
I certi4y that in the perfwmance of the work far which ihis qP pN�j�
permit is issued,I shakl not employ any person in any manner
so as to bemme subject to the Workers'Compensotion Laws. LigMinq Fixtures First 20 ADDRESS
Total No. Addi�ional
Date Applicant CITY Tel.No.
Fized Appliances Nof Over 1 HP PERM�T EI i-I�.e E{ec�ric�
NOTiCE TO APPLICANT: If, after moking this Certificate ot AGRKANT
Ezemption, you should become subject to the Workers' Range�Heater_O.W.— ^, .
Compensation pravisions of the lobar Code.Yau musf forih- Ovan _Dryer _W.M._ ADDRESS 525' � ,�-�Ve
with comply with such prrnisions or this permit shall be Fop _FAU —W.H.— CITY � Tel.N
deemed revoked. � � � �� ���� � Hood _Fan _Other_ � V� � ��g �
LICENSED CONTRACTORS DECLARATION . ��Ng pq
I hereby affirm tFwt I am licensed under provisions of Chapter 9 Disp. —Room Air Cond. — Q.' � Class.C'�O �
REG.NUMBER
(commencing with Seclion 700�)of Division 3 of Ihe 8usiness DfSTRIGT NO. PR SSED BY
and Prafessions Code,nnd my license is in f�ll force and effecr. Power Apporafus 8 Large Applionces � a
4��Z4 Z G—�� Size 8 Type HP,KW,KVA,or KVAR � !
License Num6er Lic Class Up to 1 Intl. F�N,44 }
��I�c G 1"e�• �L+� S3 Over 1 to 70�ncl. DA� �� � /ZD --� VALIDATION 0 7
ContraUor Dafe �
❑ Over 10 to 50 InCL V
FlNAL
I am eaempt under Sec. Over 50 to 100 Inc BY W
6.8P.C.for ihis reason Over 100 v�f �
� Servicea,Swbd.,MCC 8 Ponefboards � � . � x �
Date: 0-200 Amp.Under 600 V � �
�
Signature 201-1000 Amp.Under 600 V '
DOver 1000 Amp.or Over 6W V
Ezemption for Reg-Moint.Eled.
SINGLE FAMIIY Temp.Power Pole&Appurrenonces _
HOME OWNER-BUtLDER DECLARAiION ${g�Nrith One Bmnch Circuit �= � �� �-��� •�
I hereby affirm that I am exempt from the Contractor's LicenSe qddifiono4$ign Branch Circuits
Law for ihe following reason(Section 7031.5, Business and ,, � • _ _ �
Professiorts Code): � .
❑ 1,as owner of Ihe property,will do the work nnd the Misc.Conduits 8 Conductors j .. ,. ;_ , ,
st�ucWre is not inlended or offered for sale (Section Other($ee Complele Fee Schedule)— �
7044,8usiness ond Professions Code�. ' ° " � '- - ' �
GONSTRUCTION LENDING AGENCY
I hereby affirm ihat there is a construction lending agency for
the performonce of the work far which this permit is iss�ed PERMIT FEE � (Suh-Totul) ��"�'��� � - �
(Sec.3097,Civ.C.).
PLAN CHECKItJG FEE �
Lender's Name /D �
PERMIT ISSUING FEE (
Lender's Address ,/
i tertify that I have reod this application ond sta�e that the � TOTAL FEE
above informa�ion is correcl.I ogree to comply with all County �
ordinances ond State laws regulming Eleciriml wiring,and �
hereby ou�horize�epresentatives of ihis County lo enier upon .
��the bove-menrioned prope�ty for Inspection purposes. SEE REYERSE POR EXPLANATORV tANGUAGE
��`�'1�op� ��-2 rr�3
Signarure of Permillee Dote
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