HomeMy WebLinkAbout0883A (4) WORKERS'COMPENSATION�ECLARATION �enn663 tOiBi APPLICATIOM FOR E�ECTRICA#. PERMIT � I
I hereby affirm thaf I have a certificate of conseN to self CE-806G
insure�or o ceil�fimfe of Wo�kers'Compensation Inwrance, COUNTY OF LOS ANGELES BWLDING AND SAFETY
or a certified mpy thereof(Sec.3600,Lab.C.)
PDollcy No. Company FOR APYUCAN7 TO Fllt{H pDRE55 d ""�
Cartified copy is here6y f�rnished. New Residential Bldgs.&Pools �+CH NO. fEE •
� Cerrified copy is filed with the co�nty building inspec- 1 8 2-Family,Sq.Fr. $ — S LOCALITY f���r� �- '
iion department. ' Multi-family Sq.Fi. — NEAREST � A
Residen�iol Swi nQ Poois CRO55 SL 4'J
Da�e Applitanl �()(� aQ(� �RMNAME � ,Q/j
CERTIFICATE OF EXEMPTION FROM WORKERS' r �
OuHe�s:Rec_Lighf_Sw._ •g�
COMPENSATION INSURANCE Firsr 20 DR�55
(Tht�secfion n�d not ba compbted lE tha�roek inro{vd by �iorol No. Add�i�onal CITY Tel.No.
the permlf Is for onQ hundrod dollan(5160)or f.aa.j �
PLAN CHEpC
I certify fhat in ihe performance of ihe work�for which this APPLICANT
permit is issued,I shall not employ any person in any manner
so at ta 6emme suhject m the Workers'Compensation taws. ��ghting Fizfures first 2p AD�RESS
Tatal No. Addiiional
CITY Tel.No.
� �0f PP�1C° Fixed Appliances Not Over 7 HP
NOTICE TO APPIICANT: If, a ter making thi Certificate of PERMIT
Exemption,- you shauld became stsbject tv the-Warkers' Range._,_Heatee_D.W. ._ APPLICANT [n
, Compensnfion provisions of the Eoboo-fode,you�musf forth- Oven _Dryer —W.M._ ADDRES$
wiih wmply with such provisions or Ihis permit shall be Top _FAU —W.H._
deemed revoked. � Hood _Fan _Other_ ��n Tel.No.
UCENSED CONTRACTORS DECLARATION uCENSE OR �
I hereby affirm Ihat I am licensed under provisions of Chapter 9 Disp. _Room qir Cond. — REG.NUMBER Class. �
(commencing with Section 7000j�ot�irislon 3 of the$usiness power Apparalus 8 Large Appliances DISTRICT NO. PRQCESS�Q&Y
and Professions Code,and my license is in fu8 force and-effect. i � _ _ \\ Y
Size 4 Type HP,KW,KVA,or KVAR � Y\;\(\\� 0.� f
License Num6er Lic.Class � ��"� �
Up 10 1 Ind. FINAL U �
Over 1 to 10 ind. DATE � pr �
YALIDATION
Comractor Dafe Over 10 to 50 Incl. � �
❑ FINAL V
i om exempt under Sec. Ove�50 to 100 Inc. 8Y yy
Over 100
B.&P.C.for ihis reason �N� �
Services,Sw6d.,MCC 8 Panelboards �
��e' 0-2W Amp.Under 600 V
Signawre 201-1000 Amp.Under 600 V �
Over 1000 Amp.o�Over bQp y � ��,tiy�
� Ezemptian far Reg.Maint Elect. - �`\•�\'���`-`
lr i�
SINGLE FAMILY Temp.Power Pole&Appurlenances �; � ��
HOME OWNER-BUILDER DECLARATION • !" �O�H�S F
Sign with One Branch Circuit C o.c.��
I hereby affirm�hat I om exempt from ihe Contractor's License �` �
Additional Si n Branch Grcui�s �"C1'��m 5 � ` • � •
Law for ihe foltowing reason(Sedion 7031.5, 8usiness and 9 � • •2
(P�ro7f�essions Code: � � q`\�\p
I.� �I,os owner of the proper�y,will do the work and the Misc.Conduits 8 Conductors `yN�^�"��1� ` J � • •�=lJ��%
structure is not intended or offered for sale (Section ��her(See Complete fee Schedule)_ �(� �.y �,A • �; �J C'c U L
7044,Business and Professions Code). \ 2 :h1 � � `
CONSTRUCTION LENDING AGENCY `e' 0 6.c 1 —8 5
I hereby affirm ihat�here is o construction lending agency for
the performance of Ihe work for which Ihis permit is issued PERMIT FEE (Su6-Total)
(Sec.3097.Civ.C.). �
PIAN CHECKING FEE . I
Lender's Nome
PERMIT ISSUING FEE ��
Lender's Address
I certify tha�I hove read this appliwtion ond state thar ihe TOTAL FEE
above information is correct.I ogree to comply with all Coun�y .
ordinonces ond Siaie laws regulating Electrical wiring, and
hereby au�horize representa�ives of ihis Counry to eNer upon
the abave-memioned p.operty for��spectio�porposes. SEE REVERSE FOR E%PLANATORY IANGUAGE
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TSignoture of Pe ittee ate
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