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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 �• . , ' `� , . y �-4 - \ ` \ . ;'"' �t-c � \ � � �y� G Q� L: o • r m = �r , . '^_ c � d P G v `" p� m� `� \ �`1 m-_ '" � o"a .�i ° p„� ' ^ � � '" s arna ` t t m@ s��t o� � ° � 5 m o-n m v £:�o � `• � . m .n s r o° ° �a e�' L o u 9'' rot m�.° o o ` i - � � � �� 'O� 3 � � G u� 'Ct O �" � .0 G !r ? p p �- y ' . 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