HomeMy WebLinkAbout1351A (13) 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
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