HomeMy WebLinkAbout1653A (15) WORKERS'COMPENSAT�ON DECLARATION 76A663 10/61 !
I hereby affirm that 1 have a certifitate of�consaN to self �-806G APPLICATfON FOR ELECTRICAL P�RMIT � .
insure,or a cer�ificme of Worken'Compensat�on Insorance, C�UNTY�F LOS ANGEIES B ILD{NG S�ET���_U
or tifie vpyI ther f Se 3 00 ab.C.)
� �,1`����� L� FOR A►ILICANT TO Flll IN �
P�alicy No. Company � +��/7 :
Certified copy is hereby furnished. New Residentiol Bldgs.8 P I � EACH NO. FEE A��RE55«Y L I 9�[ip�. �-�,-� �
� 1 8 2-Famil q. LOCAIITY
Certified copy i:filed with the counly building inspeo y,5 Ft E — f .�_Q
fion deparfinep1. /� Muhi-family Sq.�FL . — N64RE5T
�_� �(j. Y Residential 5wimminq Pools CROSS ST.
Date��_L.._Applicant. .._ ''�mL- OWNER OR ..
F�RM NAME
CERTIFICATE OF EXEMPT'fON FROM WORKERS' � putlets:Rec_Light_Sw._ �`�� i S
COMPENSATION INSURANCE � F.�g�p �Eu rJ �Q.{,.I IO?._-
(ihla a«Tion nead nn►fw eompMad il the wori imrolr�d 6y Total No. Additional CIN � �,�Tel.No - 5
Tha permit Is fo�o�w hu�fod dollors(5100)or loss.�. vlqN CHECK
I certify that in the performanca of iha work for which this APatKaNi
permit is issued,I sha!!not employ aoy person in ony mnnner �
so as to become subject io the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
� Totoi No. Additionol
Date �pplicant CfTY Tel.No.
`TICE TO APPLICANT: If,-after making�this�Certi4icate of Fixed Applionces Not Over 1 HP PERMIT '
� .nption, you should betome svbject t0 Ihe WOrkeri . Ronge_Heafer_D.W._ A��U+ �-
�ompensation provisions of the Lobor Code,`�you�mus(forth-� Oven _Dryer _W.M.— AD�RESS 7
wrfh comply with svch provisions or�ihis permk shall 6e Top _FAU _W.H.—
deemed revoked. Hood _Fan _Other_ GITY � Tet.No1 V
UCENSED CONTRACTORS DECLARATION IICENSE Ott
I hereby a4firm�hat t am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER� ' r- �. Class /1
(commencing with Seclion 700D)of Division 3 of the B�siness Powar Apparafus B large Appliances DlSTRICT NO. PROCES �,
and Professions Code.and my license is in full force and effecc �j� Q
'Q ���� Size d Type HP,KW,KVA,or KVAR (XJ �
� License Number�J � � Lic Class� Up to 1 Ind. FINAL V
S ���j �-�' Over 1 to 10 Ind. DA� � !�.�t VALIDATION Q
Cantracto 4�C�� Dafe Over 10 to 50 Incl. FINAL V
❑ I am exempt under Set. Over 50 to 100 int. BY u� �
B.&P.C.for this�eoson O�er 100 y
Services,Swbd.,MCC&Panelboards � � �
Date: 0-2W Amp.Under C00 Y
Signature 201 -1000 Amp.Under 600 V
O � _ Over 1000 Amp.ar Over 60p V
Exempiion 4or Reg.Maint.Elect.
SINGLE FAMIIY Temp.Power Pole 8 Appurtenances ;�i /.�- '"_
HOME OWNER•BUIL�ER DEClARATION Sign with O�e Branch Circuif � �
(� �eby affirm that!am esempt from Ihe Conirattor i License A����o���&��h.Circuih� � � � � � � +--3 ` �E °+"� � �
l i for rhe foltowing reason (Secfion 7031.5,Bosiness and
Professions Code�: .� � �L,_ _
. � I,as ownet of the property,will do fhe work ond ihe Misc Conduits 8 Conductors e - '
structure is nm intended or offered for sale (Settion Olher(See Complete Fee Schedule)_ � o � n��-L,- ;-;�
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ��^-�� •- -� '�
I hereby offirm that fhere is a construction lending agency foi
the performance of the work for which this permit is issued PERMIT FEE (Su6-Total) �
�Set.3097,Civ.C.).
PLAN CNECK�NG FEE
- Lender's Name �
PERMIT ISSUING FEE
Lender's Address � �y� Q
I certify Ihat I have reod this applimtion and state fhat the TOTAL FEE '/ J
above information is correct.1 agree to comply with all CouNy
ordinances and State laws regulatinq Eledriml wiring, and
hereby authorize�epreeentatives of this County to enter upon
tl�above-mentioned prope�y for inspetHon purposes. SEE REVERSE POR EXPIANATORY LANGUAGE
'� ,�ua-rt�c 3_o-�V_ �'
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