HomeMy WebLinkAbout0919A . WORKERS'COAIPENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT �
CE-BO6G(2�801 �
1 hereby atFrm that I hsve a certificate ot consent m se�f COUNTY OF LOS ANGELES BUILOING AND SAFETV
insure,or a certificate ol Workers'Compensatinn Insurance,or '
a ce tifi 1 r of S c.3800,La C.) �
I FOR APPLICANT TO FILL IN J09
�� . (�mpany EACH NO. FEE ADOFESS�
New Residential Bldgs.&Pools
� CertiFied copy is hereby furnished. � 1&2•Family,Sq.Ft. � — $ LOCALITV
ertlfied copY is filed with the nty 6 ' ing inspection Multi•family Sq.Ft. � CROSS 5T �
department Residential Swimming Pools OWNER OR
FIRM NAME
Dy�`? APP��ca Outlets:flec._Light Sw.� MAIL '
—�irsT 2o nooRess
CF.RTiFICATC OP XEb1PTlON PftOM WO S' Total No. � Additional CITY Tel N �
COSIPENSATION iNSURANCE PLanl CHECK } �
APPLICANT n'
(This section need not be completed if the work involved Lighting Fixtures First 20 �
by the permit is for one hundred dotlars (5100)or less.) ADDRESS
Tota�No. Additional ¢
1 certify Ihat in Ihe performance of the work for which this � CITY . Tel No. O
permit is issued;I shall not empioy any person in any manner Fixed Appliances Not Over 1.HP
PERMIT V
sn as to become subject to ihe Workers'Compensatlon Laws. Range_Heater D.W. APPLICANT � W
a
Oven _Dryer_W.M._ aooRess � � v)
Date Applicant Top _FAU"_W.H.._ Z
Hood_Fan _Other— CITY Tal N —
NOTICE TO APPLiCAN7:If,afrer making this CertiFicale of pisp. _Room Air Cond._ UCENSE OR
Gzemption, yov 5hould become subjecf ta the Workers' . REG.NUMBER �Clxs
Compensation Orovisions of ihe La6or Code,you must forth- power Apparatus&Large Applian[es DISTRICT NO. PROCESS D BV
with comply H,•ith such provisions or this permi[ shall be
deemed revoked. . Size&Type HP,KW,KVA,or KVAR • /
UP to 1 Incl. �0 Cu��/
FINAL
Over 1 to 10 Incl. DATE (� ( 6� VALIDATION
GICENS[D CON'fRACTORS DCCLARATION ' Over 10 to 50 Incl, d
1 hereby afCrm that I am licensed under pmvisions of Chapter Over 50 to 100 Ina FINAL
BY `��
9(commencing with Section 7000)nt Uivisinn 3 of the Busi- Over 100 �
ness and 1'rofessions Cnde,and my Ifcense Is in full force and � j
ettect. Services � �
0-200 Amp.Under 600 V
License Number�/D7S/D Lic.Class 201•f 000 Amp.Under 600 V .
Contractor��j.f/�=�'Date�/ Wer 1000 AmP.or Over 600 V . .
IiOS1E OWNER-AUII,DGR D�CLARA'f[ON Temp.Power P6te&Appurtenances
1 hereby affirm thal 1 am exempt from Ihe Contr�ctoPs Sign with One Branch Circuit � �
License Law fnr the tnilnwing reason (cection 7031.5,Ausi- Additional Sign Braneh Cireuits - � -�'�9�,9 A
ness and Professibns Code): .
Misc.Conduits&Conductors
� 1, az oivner of the property,will do the work and the pther(See Complete Fee Schedulel— �' � � � �2�
struclure is not intended nr oifered fot saie (Section �
70a4,Ausiness and Protessions Code). � • • •9„� �
CONSTRUCTION LENDING AQENCY
I hereby affirm that Ihere is a construnion lending agency •:e e,r9,� ��
for the performance of the work for �vhich this permi� is pERMIT FEE ISub-Total)
issued(Sec.3097,Civ.C.). , s �2 Q 7_�!� .
Lender's Namr PLAN CHECKING FEE IOne-Fourth Permit Feel ' �
LendePs Address PERMIT ISSUING FEE � , - - �
I certify that 1 have rcad this applicatlon and state that the � TOTAL FEE . � C .
above information is corcect.I agree ro comply with all County . -
ordinances nd State laws reguiating EletlHcal �viring, and � � .
�here6y rize r resrn[atives of thi5 County lo enter upon �
the v ent property far" pection purposes. .
� SEP.'REVERSE FOR EXPLANATORY LANGUACE
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