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Home My WebLink About1351A WORKERS'COMPENSATIONDECIARATION 76A�� ,�,a; qpp��CATION FOR ELECTRICAL PERMIT . � I he�eby a(firm that I hove a tertificate of consent�o self CE-B06G insu�e,o�o certifica�e ot Worke�s'Compensaron Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY Pa cerr�fiedy�,p//�/ypthereof 'S,ec.3800,Lab.C.) �O�Y��I�/'/ 7GI��,7 Pany ,1.�'�,ern�t�r:� FOR APPLICANT TO FILL IN JOB �m A�D4ESS Cerfified copy is hereby(�rnished. EACH NO. FEE . New ResideMial Bldgs.8 Pools � Certified mpy is filed wilh fhe coonfy building inspeo- �8 Z-Fomily,Sq.FL 5 — S LOCAIITY ,C � 7ion deporiment.. Multi-fomily Sq.Ft, — NEARESi Dale ppP��a�� Residentiai Swimming Pools OWN R OR CERTIfICATE OF EXEMPTION FROM WORKERS' FIRM NAmE ' / Outlets:Rec�.light_Sw._ �� COMPENSATION INSURANCE AODRE55 - � � (TFi��cfion n�ed not b�compid�d ii eh�werk involv�d by First 20 Ih�p�rmll ts for ona hundred dollan(5100)or less.) Total No. Addi�ionoi CITY Tel.No. PIAN CHECK I certily�hat in the performante oflhe work fo�which this APPIICAM � permit is issued,I shall not employ ony pgrson in any manner sa as to become subject to 7he Worke�s'Compensation Laws. ��ghting Fixlures First 20 ADORE55,3' 0 _ � Totol No. Additional qTY � Tel.No. Date- npPlimnl / '.� NOTICE TO APPUCANT: If, aiter moking this Cer�ifimte ot Fized Appliances Nol Over 1 HP PEeMrt Exemplion, you should 6ecome subjecl to the Workers' Range_Healer_D.W._ APttIfANT Compensofion provis�o�s of the Lo6ar Code,you must forlh- Oven _Dryer _W.M.— ADDRE$$ ' ' , i!h comply w'th such provisions or this permit sholl be iop _FAU —W.H.— deemed revoked. � � Hood _Fon _Other_ � CITY Tel.tJo. UCENSED CONTRACTORS DECLARATION tICENSE OR I hereby affirm thaf I am licensed under provisions of Chapler 9 Disp. _Room Ai�Cond. — REG.NUMBER Class. (commendng wilh Settion 7000)of Division 3 ai the Business power Appora�us 8 large Appliantes DISTRICT NO. � PROCESSED BY ond Professions Code,and my license is in full force and effect. � � i G� �7 . /'�� Size 8 Type HP,KW,KVA,or KVAR � �' . License Number_./J,;9`'�_lic.Classy.�ft`�`� ' Up ro 1 IncL FINAL-� � � � V ��'�. S�l d L1 7�,�-�'s Over 1 l0 10 Incl. DA� ��7. ' . YALI�ATION 0 Contmcror ��7/"� Date + � ❑ Over 10 to SO Incl. FINAL [,V v�� V I om exempt under Sec. Over 50 ta 100 Inc. BY , �. ,�v W � B.BP.C.for fhis reason Over 100 � � . y Services,Sw6d.,MCC 8 Ponelboards � �� . Z Doie: 0-200 Amp.Undcr 600 V ,. Signature 201-1000 Amp.Under 600 V � � -- ❑ Over 1000 Amp,or Over 600 V Exemplion for Reg.Maint.Elect. SINGLE FAMILY Temp.Pewer Pole 8 Appurtenonces � HOME OWNFR-BUIIDER DECLARATION Sign wiih One Branch Circuit I hereby vifirm thot I om exempl from the Controdor's License qddifionol Sign Bronch Cirwits . � _ � Law for the following reason(Section 7031.5, Businr.ss nnd � _�3�.1� � Professions Code�: �•,• ❑ �I,os owner of the property,will do the work and Ihe Miso Conduits 8 Condvcfors� � . •-F 2 slructure is not intended or offered ior sole(Settion Other(See Complele Fee Schedule)_ , � � 7044,Business and Profesiions Code). "� � �� •C Jr CONSTRUCTION IENDING AGENCY �'! • �_�•2 Jr� I hereby afiirm ihal lhere is a consirutlion lending agenty for O 7,s` the performance of the work for which this permit is issoed PERMIT FEE - (Sob-Toral) . fj,�j (Sec.3097,Ci�.C.). PLAN CHECKING FEE ' . Lender's Name I � � PERMIT ISSUING FEE Lendeis Address , I I � - . I certify�hat I have reod ihis applicoiion and stare�ha��he TOTAL FEE above informaiion is torretf.I aqree to comply wilh all Counly � �- ordinonces and 51ate lows regulo�ing Elec�ricol wiring,ond � hereby authorize represematives ot ihis Coumy to enter upon - . rhe abavelnemioned r perty o�i p`crion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ �f _ - _ al e of Permitree ate . � � T C � T � Q Z j. . . • ' O Z =� � � 7O C O - , .r y .y C � m ;'o ,• . N /_ K A m � Z N „� D � N . C �` ,•J: _ � r Q � Z � K O .. S A - Z 0 c o $ D _ � � A � �p r . 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