HomeMy WebLinkAbout1790A WORKERS'COMPENSATION DECLARATION 76Aa63 i0iei APPLICATIOi�t FOR ELECTRICA! PERMIT� � �
I hereby affirm ihot I have a cerlfficole of mnsenf to self CE-e06G �
insure,or o cerrifimie ot Workers'Compensotion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFE�
or a cenified copy thereof(Sec.3800,Lab.C.)y�,�
PQolfcy No �� ampon,�Q�'r/��'��C� " FOR ARLICANT TO F0.l IN ��B / ?
Cerfified co is hereb fumished. �ND. EACH NO. FEE ADORF55 (��j �,
PY� Y New Residenlial Bldgs.8 P o s � �/ ��` �
(� 1 8 2-Famil Ft. E = S LOCAUtY -�.
1�6f Certified copy is filed wilh the counry building inspeo Y��' NEAREST
de r ment. M�IIi-family Sq.Ft. �
Residential Swimminq Pools OWNER OR
Dote� Applicanf � FIRM NAME �D
CERTIFICATf OF EXEMPTION FROM WORKERS' Oullets:Rec_tighl�5w._ �"V`��
COMPENSATION INSURANCE aDoeE55
This aadbn eNd rto16�mm }�d if tlN work involved S First 20
( � Y Total No. Additional CIN / a,Tel.No. � y
fho p�rmif is for oaa hundr�d doUan(;100)or Ina.}
%AN CHECK
1 cerlify Ihpt in the perfarmance of fhe work for whi[h this qpp��Ge,N7
permif is issued,I shall no�employ any person in any manner
so as to become subject to�he Warkers'Compensa�ian lews. Lighting Fixtures First 40 ADDRESS
Totai No. Addirionol CITY Tel.No.
Oate Appticant Fized AppGances Not Over I HP PERMIT q
,� NOTICE TO APPI�CANT: If, aftar moking this Certificate of qpp��GqM'r� (' G
�aemption, yov sfiould become subjecf ta the Workeci Range_Hearer_D.W._
Compensotion provisions of the Labor Code,yo�musl forrh- Oven _Dryer ,W.M..— ADDRE55 ��_ ���
with comply with s�ch provisions or this pe�mit aholl be Top _FAIJ _--_W.H.—
deemed revoked. CIN f�(�9���Tel.NoJ'�'9 �
Hood _Fon _Dther_
UCENSED CONTRACTORS DECIARATION tlCFNSE OR ,pr� � �/�
{hereby atfirm that I om licensed under provisinns of Chvpter 9 ���' —Room qir Cond. _ REG.NUMBER (TC/ ��Q
(mmmencing wi�h Sec�ian 7p00)of Division 3 oi�he Business DISTRICT NO. PROCESSED BY � �
ond Profeuions Code,ond my license�s in iull force and eNect. Power Apparotvs 8 La�ge Appliances + �( ,,/��
�r,'-�6' Size 8 Type HP,KW,KVA,or KVAR t U �l`\Ci.\Q V �
licenu Number_���1�Lic Cfass 1U FINAL CC e
Up to I Ind. O �
����.�/ '� Over 1 fo 10 l�cl. �AtE 1,� S I b t VAUDATION �
Comrattor �`-4ate � � �
❑ Over 10 to 50 inti. fINAI W
I om exempt vnder Sec. Over SU to 100 Inc. BY �,���./ �
B.BP.C.for this reason Over 100 • ' `, �/`''`'`�' Z'
Date: Services,Swbd.,MCC&Ponelboards � 'µ• • d � ,_
0-200 Amp.Under 600 V '
Signature ?Ol-1000 Amp.Under 600 V � F' ° �4.:i i: �
DOver 1000 Amp.or Over 600 V o z
Eaemption for Reg.Maim,Elect.
SINGLE fAM{lY Temp.Power Pola 8 Appurtenonces Q;•,[C—i;� �
/ HOME OWNER-BUILOER OECLARATION $�9��yith One 8ranch Cirt�i� �
f, hereby atEirm�hnt 1 em esampt fiom Me Connactor e liceme�� � q d d i n o r b l S�g n B r a n c h C i r c v i�s �
Law for fhe following reason(Section 70.31.5, B�siness and
Professions Code): �
❑ I,os awner of the properfy,will do the work and Ihe Misc.Conduits 8 Conduc�ors
Strucrure is not intended or offered tor sala �Section Other(See Complete Fee Schedule)_ �
7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCV
�hereby affirm that there is a const�uclion lending agency for �� �
ihe performance of ihe wo�k for which ihis permit is issued PERMIT FEE (Sub-Tolal)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
lender's Name �
PERMIT ISSUING FEE
Lender's Address �
I tertify tha�I hove�ead this applim�ion and state thal�he TOTAL FEE �
a6ove information is cor�ecl.I ag�ee to comply wiih all County
ordinnnces ond State lows regulating Electrical wiring, ond
here6y authorize representaiivas of�his CouMy lo enter upon ;
Ihe mentioned property for inspection p o s. i
—(.=��j�'y' �L'"LJ"` `L�` /�/� SEE REVERSE FOR EXPLANATORY LANGUAGE
G � � I
Signature of Permittee Date
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