HomeMy WebLinkAbout1646A (17) WORKERS'COMPENSATION DECLARATION 76n663 10/81 '
I hereby affirm thot I have a tertifico�e of consent to self �E� APPLICATION �FOR ELECTRICAL PERMIT � �
insure,o�a cerrifkate of Workers'Compenw�ion Insurance, COUNTY OF k0$ANGElES B ILDIN AND SAFETV
or a c�C ied copy fhereof(Sec 3800, ab.C.� �-/4 � � Q
�!2-(1-��to/ o!
Dolicy No. Compvny � . FOA AP/tKAµT TQ FHL IN .- JOB �
� Certified copy is hereby fumisbed. EqCH P�p. F� AODRESS� p� - �
New Residential Bldgs.�`Po Is
� Cerfified topy is filad with fhe[ounty building inspec- 1 8 2-Family,5q.Ft./�T f — S LOCALITY
fion deparfinem Multi-family Sq.ft. — NEAREST '
CRO55 5T.
� Dote � � r� Applicant� Residential5wimming Pools pWNEROR �
FIRM NAME
CERTIFICATE OF EXfMPTlON FROM WORKERS Outlets:Rec_Light_Sw._ �+�� '
COMPENSATION INSURANCE pppgE� � u
(Thia tQtfiun nNd not ba complolad if the work Involv�d 6y Firsl 20 �
thv pormif is for one h�ndrod dollan{5100)or IQss.) Total No. ,qdd���o�� CITY Tel.N "
I�certify thm in the performance�af Ihe work�for which this � PIANCHEUc
permit is iasucd,1 shall not employ any person irt any manner �
APPLICANT
w os�o betome subjecl ro�he Workers'Compenwtion Laws. Li9Ming Fixtwes First 20 ADDRE55
Totnl No. E+ddilional
CfTY Tel.No.
�o�e opplicant Fixed Appliances Not Over 1 HP
[� �CE TO APPLICANT: If, after moking thit Certifimie of PERMIT �
Ron e_Heater_,Q_W.� APPIICAN7 1
� nption, you should 6ecome.su6ject to�th4.N/or4era' 4. ..
Compensotion provisions of the tabor Code,yau must forth- Oven _Dryer _W.M._ ADDRE55 (J �Ir
with comp}y with such provisions or this pe.m�t shall be Top _FA� _W.H.— ��
deemed revoked. Hood _Fan _pther_ C�TY ��j'U7 Tel.No. U
LIGENSED CONTRACTORS DECLARATION Lt�NSE OR
I hereb affirm thot I am licensed under rovisions of Cha ter 9 Disp. _Room Air Cond. — �' .� Gcass. � (J
1' P P REG.NUMBER
(commencing with 5ection 7000�of Division 3 af ihe Business power Apporotus 8 Large Appliances DISTRICT NO. PROCESSED
and Rofessians fode,and my license is in full force and effect. r
s,,/ � Size&Type HP,KW,KVA,or KVAR� O
liceme Number�l4,�N ,�LL ln Lic Cioss � Up l0 1 Ind. FINAL U
Over 1 to 10 In�i. DATE $ 'r' d,
CoMractor �te'� Over 10 to 50 Incl. /a�r'T VALIDATION 0
� FlNAL
I am ezempf under Sec. Over 50 ta 700 Inc. BY W
. 8.&P.C.for thi:reoson Over 100 N
Date� ��v���.Swbd.,MCC 8 Panelboards � �
0-200 Amp.Under 600 V
Signmure 20{-1000 Amp.Undar 600 V ;.;� � �, �� �
� Oaer 100�Amp.or Over 60p V �'.' ,
Exemption for Reg.Mam�.Elecf. .ii � � � e ��
SINGLE PAMILY � Temp.Power Pole 8 Appurlenonces (
HOME OWNER-BUIIDER DECLARATION Sign with One Branch Circuit - � ' '�� G'-`=%
� eby affirm thot I om ezemp�from ihe Contractor's License - _ , . _ . . . - .: r
�-t_.�for the faliawinq reason(Section 7037.5, Business and Addiliona!Slgn$rorrch�Circvin
Profeuions Code�� � � a s'? �`�'.�
❑ I,as awner of the property,will do ihe work and the Misc.Conduits 8 Conduciors _ __, ,.
OthO� ::.L'�—?:Ll
stru[tur¢ is not intended or offered for sale (Section .(See Complele Fee Schedule)_ . "
. ... .... � .
7044,Business and Professions Code�. � � ��- �
,� CONSTRUCTION LENDING AGENCY . . . ..
. 1 hereby affirm that there is a construUion lending agency for
the performance of the work for which this permit is issued PERMIT FEE � - (Sub-Total) i I
(Sec.3097,Civ.C.). .
- PIqN CHECKING FEE.. � � - � ... _ � � � I
le�dar's Name � - �
� � PERMIT�SSUING PEE �� . � � ��O� �
tender's Address � � �
I certify that I have read this applicotion and state that the TOTAI FEE � � .�. I
abova infwmotion is rorred.I agree ro tomply with all County �
� -ordinances and State laws regulnting Electrical wiring,and � � � _ �� � �
hereby aufhorize representatives of this County to enter upon - -�--� � ��- �--� -�� - -�-� - ���-� � � - -- -
the bove-menliona propeny for inspection purposes. SEE REVERSE FOR EXPIANqTORY LANGUAGE
�'�`
Signature of Permittee pote . � -
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