HomeMy WebLinkAbout1812A WORKERS'COMPENSATION DECLAR4TION 76A663 toiat �� �! I
' ����Y affirm that I have a certificate of consent to self insure, �"806G APPLICATION FOR ELECTRICAL PERMi���
or a certit�cate ot workers'Compensation Insurance,or a certified COUNTY OF LdS ANGELES BUILUING AND SAF Y�l �
copylhere t_(Sec.3800.Lab.CJ �_
r>oncr H����z�cwoPe�,y�NGVS?J'C1A'L� FOR APPLICANT TO FKL IN a�ooaess �CP
❑ Certified copy is hereby furnished. /Ni0 New Residential Bldgs.&Po �H NQ FEE ' '
� Certified copy is filed with the ounty building inspection 1&2-Famiiy,Sq.Ft. 77� $ — $ Q tOCALiFY /� � � ''�7
ment Multi-family Sq.Ft. — NEaREST /7
✓j�/��1 CRO55 Si. (J
Date qpP�{py�� ///`� Residential Swimming Pools OWNER OR
, - FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Ouilets:Rec_Light_Sw.--.. ' ^^^�� � O
COMPENSA710N INSURANCE " aooaEss /
(Thia section need rtot be completed if ihe wwk involved Ey the First 20
permit is tor one huntlred dollars(5700)a�ess.) Total No. q�i�iony� qT ��(,� � � TeL �
I certify that in the performance oi the Nrork for which this permit PLAN CHECK
APPIICANT
is issued,I shall not empbY arry person in any manrier so as to
become subject to the Workers'Compensation Laws. L'ghting Fixtures First 20 ADDRESS
Total No. ��tional
qTY Tel.No.
Date Appiicant Fixed Appliances Not Over 1 HP
� :E TD APPLICANT: tl,.af6er making this Certlficate of ���CANT// �i Y
,iption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ �./�.
provisio�of the Labor Code,you must forthwith comply with such Oven_ Wyer.,� W.M._ A�DRESS ,v. ���
provisions or this permit shal!be deemed rewketl. Top _ FAU _ W.H._ C17Y -y')�y �r
LICENSED CONTRACTORS DECLARATION Hood_ Fan _ Other_ �� �/(XJ Te�.N�9iCO
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Ai�Cond. _ IiCENSEOR /l /y,� N�/Q
(cwnmencinp with Section 7000)ot Division 3 of the Business and �+EG.raunteEa �-f 6v �%�i
Professions Code,and my license fs in fWl force antl eftect. aSrRiCi nio. PROCesseo ev
Power Apparatus&large Appliances {�
L'�/E��}�{�(y 7 �+ � Size&Type HP,KW,KVA,ar KVAR I'\0.`a h � �
License PNmber r rV�d� 7 Lia Class`
Up to 1 IncL FlNAL �
Contracta C-�Ni�Le./7t.- pate �� Over 1 to 10 Incl. DATE �_��_g y VALIDATION �
Over 10 to 5D Incl. � �
� FlNAL
1 am exempt untler Sec. Over 50 to 100 Inc. gy �
8.&P.C.for this reason Over 100 a
. �:, y
Serrices,Sw6d..MCC 8 Panelboards � := ' E
Oate� 0-200 Amp.Under 600 V �. � _ Z �
Signature 201-1000 AmP.Under 600 V " ` ... �
❑ Over 1000 Amp.a Over 600 V ,
Exemption for Reg.Maint.Elect � ° � c :
SINGLE FAMILY Temp.Power Pde&Appurtenances • c "� i - � - �
HOME OWNER-BUIL�ER DECLARATION Sign with One&ar�ch Circuit
reby afTirm that I am exempt from the Contractw's License Law U!;�`._;;;'
�wr the followirg reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits �-
Cade): . �
� Misc.Conduits&Conductors �
1,as owner of the pmperty,will do}he wwk and the shuCture �
is not intended or oNered kr sale(Section 7044,Business Other(See Complete Fee Schedule)_ � �
and Professions Code).
CANSTRUCTION LENDING AGENCV
I here6y affirm that there is a construction lending agency for the
periormance ot the wak for which ihis permit is issued(Sec.3097, PERMIT FEE � �Su6-Total) �Q
Civ.C).
PLAN CHECKING FEE
Lender's Name 0
PERMIT ISSUING FEE
Lender's Adtlress , �
I cerGty that 1 have reatl this apd�cation�and state fhat the above TOTA�FEE
information is correct.1 agree to compiy with all County adinancea '
and State laws regulating Electrical wirirg, arM hereby au[horize
representatives of this County to errter upon the above-meMionetl
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i i "C,/c�C.�c-(_ ���
Signature ol Permittee pa�
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