HomeMy WebLinkAbout1821A WQRKERS'COMPENSATION DECIARATION 76Ae63 10/81 APPLICATION FOR ELECTRICAL PERAAIT � �
1 hera6y affirm that 1 have a certifitote of tonsent to self CE�eoeG
insure,or o certifimte of Workers Compensation Insurance, �`O COUNTY OF LOS ANGELES BUILDINCs AND$AfETY
t�qY� � `y���Oe,RfJrS�3800,L�ab.r C.) W��,�e
(��`;� �its �,�L.7��'+� '� FOR APPIICANT TO FILL FN �� /�, 7�
oiic No. Com n 3�• IC�I�h Vn�e
Cerfified co is here6 furnished. EACH NO. �{E ADDRE55
PY Y New Residential Bldgs. ��p � n(�!'�
1 8 2-Famil Ft. CJ p s• — � LOCALITY u l.l
� Cerllfied copy is filed with the county building inspec- Y•�1� _
- tion department. ,�l � � Muhi-fami�y Sq.R. C OSS 5T.
Data��� A Iicant �^I�� '--'�"-"' •C' Residential Swimming Pools OWNER OR _j,�,
pp FIRM NAME � �� 10{�i
� CERTIFICATE OF EXEMPTION FROM WORKERS" � Outlets:Rec_Light_Sw._ �« �a � �..h �' . t�
- COMPENSATION�NSURANCE ADDRE55 � �
(This�ae4ian neQd aaf 4e comploMd!f Ms work invotv�d by First 20 CITV Tel.N .
e d Tatal No. Additional nQ.
IFw permit ia for ont hundrad doUars(SFOU)w�ss.)�
PLAN CHECK
1 cehify tha�in�the performonce of the work for which�this MICANT
permit is issued,V aha14 not employ any person in any monner
so as to become wbjact to ihe Workers'-Compensation Lows. ��ghting Fixtures Firs�20 AODRE55
Total No. Additional GITY Tel.Na.
Date App���a�� Fixed App�ionces Not Over 7 HP PERMIT �,y��
NOTICE i0 APPLICAIVT: If, after making this Cerlificote of pppLICANT � �� ��� 1' �C/
Exemption, you shou�d betoma subject to the Workers' Range_Heafe�_D.W._
Compensalion provisions af�he tobor Code,yau must forth- Oven _Dryer .._W.M.� ADDRESS .���
with camply wifh such provisions w �his permit sholl be Top _FAU —W.H.—
deemed revaked. Hoad _Fan _Other_ ��TY ��v'�r5��e Te�'N '���
LICENSED CONTRACTORS DECLARATION uCENSE OR �`QZ4,Z G�O
t hereby offirm thal I am licensed urtder provisions of Chopter 4 �'gP� —Room Air Cond. — REG.NUMBER C� Clau.
(commencirg with Sectian 7000}af Division 3 of the 8usiness power Apparal�s 8 lo�ge Appliances DISTRICT NO. � PR SED BY �
and Professions Code,aod my license is in f�ll force ond effect.
�t�n^� �—'h Size 8 Type HP,KW,KVA,or KVAR� Q
License Num6er �� Lic Class v Up�0 1 IncL FINAL V �
L-1�,��. G7JfC,r�^i O�er 1 ro 101nc1. DA� f�..f(�`�^'�� VALIDAiION Q �
Contracror�—� ��e � �'�'� Over 10�0 50 Incl. �
� F���
I om exempt under Sec. Over 5p to 100 Inc BY �
8.8P.C.for ihis�eoson Over 10p N
Serrices,Swbd.,MCC 8 Panelboards Z
Date: 0-200 Amp.Under 600 V � k
Signature 201-1000 Amp.Under 600 V �
❑ Ovar 1000 Amp.or Over 6�0 V
Ezemption for Reg.Mai�t.Eled.
SINGLE FAMILY Temp.Power Pole 8/�ppvrtenances j
HOME OWNER-BUIIDER DECIARATION g�g��,,��h One Branch Circuit ( ,r�. � ' �
I hereby affirm thnt I am exempt from�he Contrattor's License "��� � � � � �� �
Law far�he following reason(Section 7037.5, Business and Addifionai Sign Bronch Circvih ^
Professions Code): �'° ° ° � ���
❑ I,as owner of the properfy,wil)do the work and the Misc.Condui�s&Conductors
Ofher See Com lete Fee Schedule � ° ''' '`�'-��
slrudure is nar intended or offered for sale (Section ( P �—
. 7044,Business and Professions Code�. � a � . . '-?
CONSTRUCTION LENDING AGENCV ,
� I hereby affirm tha�the�e is a consiruction lending agency for U�+'�.�r��' ..�,
the performance of the wo�k for which this permit is issued PERMIT FEE (Sub-Total� �
(Sec.3097,Civ.C.). �
p(AN CHECKMG FEE �
Lender's Nome � - /D
PERMtT ISSUING FEE
Lender's Address
� I rertify tha�I have read this applimtion and siate ttwt the TOTFLL FEE �
above infomwtion is correct.I agree to comply with all County
ordinanres and Stale laws regulating Eleciriml wiring,and �
hereby authorize representatives of Ihis County to en�er upon
�the bo�e-mentioned property fo�inspeUion purposes. SEE REVEKSE FOR EXPLANATORY IANGUAGE
ia.,�a o`!° �Q�.c. 8-2�=83 �
Signotu�e of Permiuee Date
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