HomeMy WebLinkAbout1001A WORKERS'COMPENSATIONDECLARATION � 7aA663 �o,e, APPLICATION FOR ELECTRICAL PERMIT ��,
I hereby offirm ihat I have a ceriificote of consent�o self CE'eoe�
Insure,o�a ce�rfmte of Wo�kers'Compensatio�Insumnce, COUNTY OF l05 ANGELES BUILDING AND SAFETY
or a tertiiied'copy thereof(Sec.3 La6.C.� �`.a �
POalfcy No. Compony���`-� FOR I1Itl1UNT TO FlLL M � I,/r IO � yy�f
Certified copy�s hereby turnished. New Residential Bldgs.8 Pools EACH NO. FEE ADDRE55 O�(
�Certified copy is filed with the county building inspec- 1 8 2Family,Sq.FL 5 = E �OCA��TY ���.y� 2' _
tio depp�menl. .{� �- Mulli-family Sq.FL NFARE57 ,C' 1 U �µ��
� 7�L tC��{��-� �1�`xh/✓ Residen�ial Swimming Pools pWNER OR J t` P� t � 1
oare t (L I u � APPlicanl� "'— ^7� FIRM NAME �b'r5�`✓
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlats:Rec�Light�,_.Sw.:�_• '�"A�� `�� rJ
COMPENSATION INSURANCE + /v SV ADDR �.,Z( e�7 C� t, V
This sacffen ns�d nof b�com lahd ti}hs work Inrolv�d First 20
� P �' Tofol No.( Addirionol CIN LTeI.No.�''����D�
Iha permit 1�for on�hundr�d dollen(5100)or Ins.J P�AN CHEIX r �
I tertify that in ihe performance of�he work for whith this qPPI�CANT -/ l
permif is issued,I sholl not employ ony person in any manner ' J ��/ �
so as�o become subject to the Workers'Compensation Laws. li9hting FiaWres First 20 �� ADORE � S�
Additionol
� � � � Total No.� CITY �A-�,Ly q,�Tel.No. GQ-9r(�
Da�e /+ppliconf Fixed Applionces Nol Over 1 HP pERMIT ' r–
NOTICE TO APPLICANT: Ii, ofler making this Certificote of Ran e_Heo�er_D.W.— AapliC4NT 'l� S � � F
Eaemption, you should become subject to �he Workers' 9
Compansation provisions of the Lobor Code,you must forth- Oven _Dryer _W.M.— ADDRESS „� �C�V(t
with comply with such provisions or this permil shall be Top —FAU _W.H.— CITY .0 Tel.No. /
deemed revoked. � � � r/�– ��
Hood _Fon _Othar—
LICENSED CONTRACTORS DECLARA7ION , � uCENSE R f�
I hereby offirm thal l am licansed under provisions of Chapter 9 Oisp. _Room Air Cond. — REG.NUMBER `�V�p Clau.
(commencing wi�h Sed�on 7000)of Divis�on 3 of the Busine:s DISTRICT NO. PROCESSED BY
Power Apparo�us 8 lorge Applionces Y
and Professions Code,and my license is in full force aos(effed: /l /'1 nc /(��✓ O
n � . U � Size 8 Type HP,KW,KVA,or KVAR U �7 Y� l,
License Nu } �t��� .Closs 17/ � - Up to 1 Incl. FINAL - - V
! . {I�L/Ly Over 1 to 101nd. DATE - VALIDATION �
Conlroctor ate �a . Over 10 fo 50 InCL FINAL {,~,!
❑ I am ezemp�under Sec. Over 50 to 100 Inc. BY W
d
B.BP.C.for this reason Over 100 �
. ._ Servites,Sw6d.,MCC&Panelboards ► �� ?
Date: �0-200 Amp.Under 600 V �
Siqnoture . 401-100D Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V _
Exemptian for Reg.Mainf.Elect.
SINGLE FAMIIY Tem Powar Pole 8 A urtenances �
HOME OWNER-BUILDER DECLARATION S�gnPwith One Branch CPcuit �� �Q 1 �
I hereby affirm�hai I am e.empl from�he Contractor's License Addirional S�gn Branch Cir�uiis #• • • • ��
Low for tl�e following reason(Section 703I.5,Business ond . �
Professions Code): f e �2�O 0
❑ I,as owner of Ihe proper�y,will do the work and Ihe Misc.Conduits 8 Conducfors
structure is not intended or offered for sale(Seclion Other(See Complete Fee Schedule)_ , . •2�Q O`
7044,Bosiness and Professions CodeJ. � "
CONSTRUCTION IENDING AGENCY � . O��_� 2`H 4.._
I hereby afiirm that there is a construction lending ogency for
� the performonce of�he work ior which ihis permi�is issued PERMIT PEE (Sub-Total) -
(Set.3097,Civ.C.).
PLAN CHECKING FEE C �-- � ��
Lender's Nome
� PERMIi ISSUING FEE . QQ ,
lender's Address /
I certify ihot�hove read this applim�ion ond stote ihat Ihe TOTAL FEE /
obove informotion is correct.I agree to comply with all County �
ordinantes and Stole laws reguloting Electrical wiring,and . �
he by uthorize represen� tives f�his County ro enter upon
e e toned o rt � inspec�ion purposes , SEE REVERSE FOR EXPLANATORY LANGUAGE /
. ���z��-y I
Si �)re of Permittee Date ' �
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