HomeMy WebLinkAbout1213A (11) -- �
WORiCERS'COMPENSATIONDECLARATION �Ee�'°'a'� APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm �hot I have a certifitate of consent�o self
i�s�re,or a ce�tifimte oi Workers'Compensoro�Insu�ance, COUNTY OP LOS ANGELES BUILDING AND SAFETY Z
or a certified copy thereoi(Sec.3800,lob.C.)
P❑Ol�iCy No. Company FOR AP►LIUNT TO FILI IN JOB -
Cerlified copy is hereby furnizhed. New ReSidenliol Bldgs.&PoolS EACH NO. FEE A�DRE55 E r �1? (f 11v �.
� Cerrified copy is filed with the mumy bvilding tnspec- �g 2-Family,Sq.Fr. E — f IOCALITY -Mp� �-(Z C(�7/e 5
lion deportment. Muhi-family Sq.R. — NEnkeSi
Residen�ial5wimmingPools � Ce0555T. � u�j� Q��V� ����Vfr�
' Da�e Applicant OWNER Ort--- � Y
FIRMNAME C.,�- �1�. O1C �p� �YY�a
CERTIFICATE OF EXEMP710N FROM WORKERS' � nnna
Outlets:Rec_Light�t`Sw.�
COMPENSATION INSURANCE ,�j Firs120 3 ADDRESS � f�Y'f�f. _
(This�eN�en naad nof ba eomplet�d if fha work Involvad by Total No.�Ld� CITY — Tel.No� � �-7�
Th�parmit i�for on�hundnd dollors(SI00)or Im+.) Additional �/� � -�J`
I certily that in the performonce of the work for which this � qppNCANTK uyYC, •
permil is issued,I sholl not emp ony person in any nner
so as�o become subject io the W rkers' omp otio aws. Lighting Fiztures Firsf 20 ADDRE55 �'
� � Total No. Addilional .
� CITY Tel.No.
Dafe applicaN Fi:ed Applfances Not Over 1 HP fgRMIT
NOTICE TO APPLICANT: If, after 'I ing this Certifimte of APMICANT �
Eremption, you shouid become subject to the Workers' Range_Healer_D.W._
Compensarion provisions of rhe Labor Code,you must forth- � Oven _Dryer _W.M._ A�DRESS
wilh [omply with such provisions or Ihis permit sholl 6e Top _FAU —W.H.—
deemed revoked.� � � Haod _Fan _O�her_ CITY Tel.IJo. :
LICENSED CONTRACTORS DECLARATION uCENse OR
1 hereby affirm thot I am licensed under provisions of Chap�er 9 Disp. _Room Air Cond. — aEG.nnIMBER CIOTS.
(tommenNng wilh$ection 7000)of Division 3 ot Ihe Business � DISTRICT NO. PROCESSED BY
�and Professions Code,ond my license is in full force and effect. Power Apparatus 8 Large Appliances- /O , }6
Size 8 Type HP,KW,KVA,or KVAR �
Li[ense Number Lic.Class FW V
Up to 1 Incl. '
Over 1 to IO lncl. � ' � VALIDATION � �
Conhactor pote Over 10 l0 50 Intl. � � O �
DFIN ~
I am e.empl under Sec. Over 50 to 700 Inc. BY 4
6.8P.C.for Ihis reason Over 100 H
Services,Swbd.,MCC 8 Panelboords � ' ? �
Date: 0-200 Amp.Under 500 V
Signorore 201-1D00 Amp.Under 600 V -- � �
❑ Over 1000 Amp.or Over 600 V . . . .
Ezempfion for Reg.Maint.Elecf.
SINGIE FAMILY Temp.Power Pole 8 Appur�enances '
HOME OWNER-BUILDER DECLARATION - Sign wilh One Bronch Circuif �
I hereby oitirm Ihol I om e�empl from fhe CoMrodor's License qdditionnl Si�n&anch Circuits
law(or the(ollowing reason(Sec�ion 7031.5,Business and
Professions Code): , • . � �
❑ I,as owner of Ihe ro er Misc,Condui�s 8 Conduclors � =� G�.�J{�-
p p ty.will do the work and the Olher $ee Com lete Fee Sthedule_ , �
strvdure is nol intended or ailered for sale(Section ( P ) �� � � e �2 .
7044,Business and Professions CodeJ.
CONSTRURION IENDING AGENCY 4 0 o Q a S O /�
I hereby offirm�hat the�e is a conshuction lending agency for �2 8 5 0=
Ihe per(ormance of the work for which this permit is issued PERMIT FEE �Sub-Tofol) � ° ° �' ,
�se�.so9�,c�.e.�.
PLAN CHECKING FEE �� � . Q�`�� -8 7
lender's Nome
PERMIT ISSUING FEE �
lender's Address
I cerlify that I have read�his opplication ond sto�e thot the TOTAI FEE ��S _
bove iniormotio is correct.I agree lo mmply wiih all Covnly
rdinance n St e law regulating Elettriml wiring,and _
ereby a h ri e re rese alives of this Counly to enfer opon - " "
e obov - ention d -inepeclion p poses. . �-
� ,��� SEE REVERSE FOR EXPLANATORY LANGUAGE /
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t re of Permiltee Date /
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