HomeMy WebLinkAbout1799A WORKERS'COMPENSATIDN DECLARATION 76A663 ,o�e, qppLICATlON FOR ELECTRICAL PERMIT � l-1
I hereby affirm that i have a certiiicate of consent to self insure, �-BoeG �
or e certificate ot Workers'C«nt�ensation�nsurance,or a certitied COUN7Y OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.38G0o,tab.C.) /
Policy NO•�-•���a Comparry/N�iI.�L.IA'�/i� FOR APPLICANT TO FlLL IN ,IOB
❑ Certified copy is herehy turnished. �Nf-�, New Residential Bldgs.8 Poo EACH NO. FEE ADDaEss(p .� � /
� Certified copy is filed with the county 6uilding inspection �8 z-Famiry,Sq.Ft.� $ _ $ LOCALITv � / ��
� �n Multi-family Sq.Ft. cEROSs 57.
� Date ��^' � l�plican Resitlential Swimming Pools pyy�q pq �
FIRM
CERTIFICA7E OF EXEMPiION FROM WORKERS' �rtlets:Rec_Lipht_Sw.— �A�
� COMPENSATION MlSURANGE ADDRES .-�- JG
(Tkxs section need�t tw eonmfetesl H the work in�Wve6 hy the First 20
permit ie for are 6uodred dofkrB($t00j a Ia88.� TOtal No. Additional CIT `N� 9'� � Tel.N. „�!�
f certi(y fhat in ttre parfamflr�ce of the work for whictv tFws permit PLAN CnECK
i8'lq9ued,I Sllell fi01 CtiiplOy 311y p2fSOf7 ill a�manner so as ro APPLIGANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additionel GTY Tel.No.
�1e �p��$�t Fized Appfiances Not Over i HP
� -'CE TO APPLiCANT: It, after making this Certificate of A��NT�f�� �' i
.ption,you staub become subject ho fhe Workew'Cmmpensation HanBe� Heater____ �.W. _
ADDRESS � /�
provisions of th6 labor Code,you rtn+st torthwith comPly with such Oven_ Dryer_ W.M._ J[
proirisions or this Dermit Sh111 Oe tleemed revoketl. Top _ FAU _ W.H._ Q� p.
LtCENSE�CANTRACTOFiS�ECLARATION Hood—Fan _ Other_ �TY �� f 7(�Q TB�'N° S �� �
I hereby affirm that I am licensed under provisuns of Chapter 9 DisO� — Room Air Cond. _ �E�E� � qas�'/(f
(commenCin9 with$CC[idt 700��of Qntision 3 of the B�uirress arn! REG.NLIMBE �
Professiona Code,aM my license is in full force antl effect. p�r Apparatu5 8 Large Appliarices OISTRICT ND. PROCESSED BY
�+ l C� 'M��o e. o �
Size 8 Type HP,KW,F(VA,o�KVAR
Lkense Num6er��Z�Lic.Class `�� UP M 1 Incl. FINAL ) V
�—�� Over 1 to 101nc1. �TE J� �'g9 VALIOATION �
Gontractorf.=���ate �� � �
Over 10[a 50 Incl. F��
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
6.8P.G.tor this 2ason Dver 100 y
ServiCes,Swbtl.,MCC&Parielboartis � ;: t ��4,� Z
Date: D-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V �; • • e c n i
Over 1000 Amp.or Over 600 V
� Exemption fOr Reg.Maint.Elect. � s j � ;;, "
SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILOEfl DECLARATION Sign with One Branch Circuit ° � I 1 : � .
� by affirm that I am ezempt from the Contracfor s License law
t., ..s folbwing reason(Section 7031.5.Business and Professions ��ipna�Sgn&anch Circuits fi:.j i—�,�•?
Code):
❑ will do the work and the structure Misc.Conduits 8 Conductors
I,as owrer ot the property,
is not intended or offered fa sale(Section 7044,8usiness Other(See Compiete Fee Scheduie)_ �
and Professions Code}.
CONSTRUCTION LENDING AGENCY
I hereby atfirm that There is a consiruction lendin�agency for ihe
performance of the work for which this permd is issued(Sec.3097, pERMiT FEE (Sub-Total) �
Civ.GI.
PLAN GHECNING FEE
Lender's Name
PERMIT�SSUING FEE D
Lsnder's Address
I certily that 1 have read this application and state that the above TOTA�FEE /�s,
intamation is correct 1 agree to comply with all Cwnty ordinances
and State laws regulating Electrical winng, and hereby authorize
representatives ot this Gounty to enter upon the a mentioned
propert ta inspection purposes. SEE REVERSE FOR EXPLANATORV LANGUAGE
ff'�"�e 9/S �
Signature of Permittee Date �
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