HomeMy WebLinkAbout0909A (4) WORKERS'COMPENSAT[ON DECLARATION 76A663 ppp��CATlON FOR ELECTRlCAL PERfi�IT
CE�B�fiG 12�80) �
I heteby at�rm that I ha�e a cettificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY i
inaure,ur a certificate of Workers'Compensation Insurance,or i
a certi�ed copy thereoP(Sec.3800.LaD.CJ ' �
FOR APPLICANT TO FILL IN �pg ��/]���
� Policy No. Company . AODRESS ����+J
New Residential Bldgs.&Poois �ACN NO. fEE
� Certified copy is hereby furnished. 1&2-Fami{y,5q.Ft. $ — $ LOCALITV ��,�„��
� CertiCied co y g� p Multi•famity Sq.Ft. N AHEST
py is filed with the count 6uildin ms ection Residential Swimroing Pools CROSS ST
department. OWNER OR ,_`�
PIRM NAM ���{��
Date Applicant Dutlets:Rec,_Light_Sw._ ADDRESS � 1o�'�W KS
First 20
CERTIFICATE OF EXEMPTION FROM l4'ORKHRS' Total No. Additional CITY Tel No. y
COMPENSATtONINSURANCE ` a
PLAN C O
(This section need not be compteted if the work involved APPLICANF V
by the permit is for one hundred dollus ($100)or less.) Lighting Fixtures First 20 qDDRESS
Total No. Additional O
I rertify that in th performan of the rk for which lhis Fixed ApD�Fances Not Over t HP GTY Tsi No. U
permit�iseued,I hall nof emp oy any pers n in any mannet PERMiT
so as to become ubject the kers'Co pensat�on Laws. Fange_Heatei D.W._ APPIICANT � a
Oven _Dryer,W.M.� ADORES5 y j
Date plica ` � 7oP —FAU _W.H._ ���� , Z 3
Hood—Fan _Other— CI7Y Tel Na �� �
NOTICE TO PPL{CANT:If, fter making this CertiPcate of Oisp. _Room Air Cond._ LICEN3E O !� /J �+y, �
Exempti n, you should 6ecome subject to the Workers' REG.NUMBER �i7�lass VJ �
Compensation provisions ot the Labor Code,you must forth- ppwer Apparatus&Large Appiiances OISTRICT NO. PROCESS�p BY
with compty with such provisions or this permit sNall be
deemeQ revoked. Size&Type HP,KW,KVA,ar KVAR f Q ��X
Up to 1 InCI. FIMAL
. Ov¢r 7 to 70 InCI. DATE
LICENSF:ll CONTRACTORS DECLARAT[ON Over 10 to 5�Incl. � 3 VALI�AT�ON
[h FINAL �
Y affirm that I am licensed under provisions of Chapter Over 50 to 700 Inc. gY .:�
9 (com enc with Section 7000)of Divislon 3 of the Busi- Over 700
us and�Y�rofes ns Code,and my license is in fuii force and �
effect. ,. Services �
Licen m r � Lic.Class 3 � a200 Amp.Under 600 V
201-1000 Amp.Under 600 V
h ct Date Over 1000 Amp.or Over 600 V
HOME OWNER-BU[LDER DECL RA ION Temp.Power Pole&Appurtenances `�4�S H �
[ h e r e 6 y a t f i r m t h a t I a m e x e m p t f r o m t b e C o n t r a c t o r's Sign with One Braneh Circuit �y• • • � •�
License Law for the following reason (Section 7031.5, Busi- AdditionaY Sign Branch Circuits
ness and Professions Code): � " �����C �
Misc.Conduits&Canductars fI
� I, 2s owner nf the property,will do the work and the Otber(See Complete Fee Schedulel— ` � ���'`S'�� ' 1
structure is not intendeJ or offered for sale (Section �
7p44,Business and Professions Code). � C;G(�-81 �
CONSTRUCTION LENDING A(3tiNCY
I hereby aftirm that there is a construction lending agency .
(or ihe Petformance of the work f�r which this permit is pERMIT PEE (Sub-Total)
issue d(S ec.3 0 9?,Civ.C J. i
- Lender's Neme PLAN CHECKING FEE (One-Pourth Permit Fee) I
�
Lender's Address PERMIT ISSUING FEE i
E certify that {have read this application and state that the TOTAI.FEE �� � �
above information is correct.[agree to comply with ail County ,
I
ordinances and State laws regutating Electrical wiring, and , .
�hereby authoriae representatives of this County to enter upon ,
"the above-mentioned property for inapection purposes. SEE'REVERSE FOR EJCPLANATORY LANGUAGE �
Signature of Permiltee Date J I
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