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HomeMy WebLinkAbout1775A WORKERS'COMPENSATIONDECLARATION 76a663 iOiBt qpp��CATfON FOR ELECTRfCA! PERMiT — 7� I hereby affirm ihot I have a cenitimte ot consent io self �-� � ',, insure,o�a cerriflwre ot Wo�kers'Compensaiion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFEi `� or a terli4i/e�d.c��o y,,,t�h�ere�of($ec.3800,Lob.C.� P�ol�i[y No��Compony�ND(/S�//9'L/� IOR APPLICANT TO FILL IN �OB /� ` 1 Certified copy is hereby furnished. , ��Y, New Residenfiol Bldgs.8 ols EACH NO. FEE ADpRESS�O�� �J, r/ �/ � 1 8 2-Famil Fi.� s — S IOCAIIT � � / � Certified copy is filed with the uMy building insper Y�59� fWD eparf enf. Multi-fomily Sq.Ft. — NEAREST n y fyy, caass sT. ,CJ ` �� ��� Residentiol Swimming Pools OWNER OR Date Applicant FIRM NAME N CERTIFICATE OF EXEMPTION Fi2pM WORKERS' Outlets�Rec_LigM_Sw._ �« � L�� COMPENSATION INSURANCE First 20 ADDRE55 (Tbia soction naad nw 6�compieMd N tin work involvad by Toral No. Add�t�onal ��T �l/ � �`,Tal.No Th�parmif ta far ww 6unMod dollars(:100)or to��.f pLAN CHECK �certify�hat in the performance of the work for which this APPLICANi parmil is issaed,I shalt nol employ any person in any manner so as to become subjac�to thg Workers'Compensotion Laws. li9hfing Fixtures First 20 ADDRESS To1a(No. Additional Dale /+ppiicant QTV Tel.No. � iixed Appiiances Not Over 1 HP PERMIT VOTICE TO APPLICANT: If, oflar meking this Certifimte of / A � � cxemptfan, yau should 6ecome su6jed to the Workers' S APPUG4NF� Ran e_Heater_D.W.— r � Compensation pro�isions of ihe Cabor Code,yo�must forth- Oven _Dryer _W.M._ ADDRE55 , i wi�h comply with such provisions or this permit shail be Top _FAU �W.H.— � x /// ,/ f deemed revoked. CITY �9i7v Tal.No,59�r(p� � tlCENSED CONTRAf70R5 DKtARATtON Hood _Fan _O�her_ Dis �Room Air Cond. — ItCENSE OR � �+/O I herebY affirm that I om licensed under porisions af Chapta 9 �' REG.NUM6ER Class. a (commencing with Section 7000)of Dirision 3 of the Business DISTRICT NO. PROCESSED BY � and Professions Code,ond my license is in full force and effect. Power Apporatus 8 Lorge Appliances �) ���jj�,��1/�)' f�� �!' Size&Type HP,KW,KVA,or KVAR ![/ Q'G U License Num6er�y���Lic Class �� 4 tJp to i lncl. FINAt QS ������4 Date �-o ' Over 1 to 101nc1. DATE ��a��4l, YAL{DATIOH � � 0 Conlroctor Over 70 ro 50 lnd. W ❑ FINAL I am exempt under Sec. Over 50 to 100 Irrt. BV �n � a� B.&P.C.for rhis reason Over 10p t V� z Service:,Swbd.,MCC 8 Panelboards � Date: 0-200 Amp.Under 60p V ��`'� l 1�.�i N Signoture 2p1-1000 Amp.Under 600 V TM� ` c _ , � ❑ Over 1000 Amp.or Over 600 V °`` � Exemption for Reg.MainL Elecl. + ��`` _ ,_ SINGLE FAMILY Temp.Powe�Pole 8 App�rferwnces � t- HOME OWNER-HUILDER DECLARATION Sign with One 6mnch Clrevit " • °�' �- - ` .hereby nHirm thaf I am exempf from the Conhocfor's Licensa qdditional Sign Bronth Circuih ^ � Low for the following reason i5ection 7031.5, 8usiness ond ��J,C C—: G � Professions Code): � ❑ I.as owner of the p�operty,will do the work and fhe Misc.Conduits 8 Condudors shucturo is not intended or offered for sale(Section Other(See Complele Fee Sched�le)_ � 7044,Business and Professians Code). � CONSTRUCTION LENDMG AGENCY � I here6y aHirm ihot�here is o mnsiruction lendin9 ogency for fhe performance of the work for which Ihis permit is issued PERMIT FfE (Su6-To�el) (Sec.3097,Civ.C.�. � PLAN CHECKING FEE � Lender i Name ' ' PERMIi ISSUING FEE Lender's Address I certify tha�I hove read this applicotion ond staie ihat�he TOTAL FEE ��� j above information is correU.I agree ro comply with all Caunty � ordinances and S1ate Ivws regulaling Eletlricol wiring, and her y outhorize representoiives of ihis Coun�y to enter upon e ove-me��ioned properiy for inspecti n p rposes. 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