HomeMy WebLinkAbout1649A (17) WORKERS'COMPENSATION DECLAR.4TION ��� ���8� APPLICATlON! FOR EL�CTRICAL PERMIT j`�
I hereby affirm ihat I have a cenificote af tonsenl to self �-�
insure,or a certifitate of Workers'Compensat�on Insurance, COUNTY OF I.QS ANGELES BUILdING AND�FETY L�
or o certifi(edf cop th f Set.3800 Lob.C.� 7' 3' �
-+z��- ����f FOR APM�CANT TO Flll IN JOB � ��
PQolic�.No. fompany� ��- ADDR
Certified copy is he�eby furnished. New Residential Bldgs:&Pools �H �' �EE
/�(p s Ll _ g LOCALITY �
�Cerfified copy is filed wifh the co�nty 6uilding inspec- �8�-Family,Sq.Ff. . I
ti9^departme t. Multi-family Sq.Ft. �R�p,R55 5T.
Dale v 4~ Applicon� �S ReSidential Swimming Pools �RMENAME
CERFIFICATE Of EXEMPTION FROM WORKERS' Outlets:Rec_LigM_Sw._ �� �
� COMPENSATION lNSURANCE nooaEss
Thi��xfbn nwd not b�cwn if Nw wo�k inrelr�d h First 20 ��TY Tel.No.�
( ab+od r roroi No. ndd�ro�oi ✓ ���
Iha porml�ia ior ono hundrod defi�n(5100)or loss.) PLAN CHECK
I certifY thnl in the perfo�monce of Ihe work�for which this APttICANT �
permit is issoed,I shall not empfuy ony person in cny nwnner
so as�o become subjeci to the Warkers'Gompensation taws. ��9hting Fietures First 20 A�DRESS
� � Addi�ionol
� Totol No. CITY Tel.No.
Date -oppliconf Fixed Appliances No1 Over 1 HP PERMIT
t"'�- TICE TO APPLICANT: If, af�er making ihis Certifimte of . q7pLICANT �.
np�ion, yau should becoma su6ject ro the Workers' Raoge�_.Hoater_D.W.— /.,
��. ��ompensotion provisions of tlro tobor-Code,yoo musf fonh- Oven _Dryer —W:M.— ADDRESS /3;�(
� wieh�comply with auch provislona or lhis permit ahali be Top� _FAU —W.H.—
deemed revoked. GTV ,d-�G� Tal.Na. ��d
Hood _Fan _O�her_ �
UCENSED CONTRACTORS DECIARATION IICENSE OR �
, I hereby affirm ttat I am licensed under provisions ot Chopter 9 Disp. _Room Air Cond. — REG.NUn58Ett ,� Class. �f
(commencing with Section 7000)of pivision 3 of the Buslnesz OISTRICT NO. PROCESSED 8
Power Apparat�s 8 Large Appliances � /� >
e�d Profesaions Code.a�my licensa is in full torce and effed. //Zj ( / O
« ./��, /� Size 8 Type HP,KW,KVA,o�KVAR �F�" �
License N�m6er �f Lit.Class C �a � �P fo 1 Incl. FINAI V
�j�� Over 1 to 10 Ind. DATE /��� � � VALI�ATIOH �
� CoMrnetar pote ��<*""— `l . 0
Q � Over 10 to 50 Ind. FINAL p U
1 om exempt onder Sec. Oaer 50 to 100 Inc. gY � i A�Y' ,,.�— y
d
Over 100
B.BP.C.for this reason �
pa+e. Services,Swbd.,MCC&Panelboords �
. 0-200 Amp.Under 60D V �
Signature 401-1000 Amp.Under 600 V
❑ Over 100D Amp.or Ove�600 V � ^
Ezemption frn Reg.Mainr.Elect. � � ' �
S{NGIE FAMIIY _ . .. Temp,-PowerAole-B�Appurterwnces ;; • •l' �
HOME OWNER-BUIL�ER DEClARA710N � � Sign with One�Bronch Circuit� � . .. � � � � � --��
� eby affirm thar 1 am ezempt fmm the Cqntrocroi slicense. Addi�ional Sign Brar,ch Circuih � ' �?? `1
__,.�for the following�eoson(Seciion 7031.5, Business ond
- Professions Code}: _,,. .�
❑ i,as owner of the property,will do Ihe work ond the Misc.Conduits&ConduUors ��y�6_^
strudure is not lmended ar offercd for saie(Section- Other(See Complete Fee Schedule)_ � l::i.c:'„�"� .. -
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY �
I hereby affirm ihat there is a tonslruclion lending ogency for
�he per4ormance of the work for whith ihis permit is issued PERMIT FEE (Sub-Total) ?3
�Sec.3097,Civ.C.). .
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �Q Q
Lender's Addrass �
I certify that 1 hnve read Ihis applimtion and s�ate Ihot ihe TOTAi FEE
obove information is correct.1 agree to wmpty with oll County �
ordinances and State laws regulviing Elecfricol wiring,and
hereby auth.orize representatives of this County to enter upon
�he a ve-me�t�oned roperty far inspedioa p�rposes. SEE REVERSE FOR E7(PLANATORY LANGUAGE
�����
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